DIAGNOSIS 


OF 


GALLSTONE   DISEASE 


KEHR 


INTRODUCTION 

TO   THE 

DIFFERENTIAL   DIAGNOSIS 

OF   THE 

SEPARATE  FORMS  OF 

GALLSTONE  DISEASE 


BASED   UPON 


HIS  OWN  EXPERIENCE  GAINED  IN  433  LAPAROTOMIES 
FOR  GALLSTONES 


BY 

PROFESSOR  HANS  KEHR 

HALBERSTADT 


A  UTHORIZED   TRANSLA  TION 


WILLIAM  WOTKYNS  SEYMOUR,  A.B.,  Yale,  M.D.,  Hap\ard 

FORMERLY    PROFESSOR    OF    GYNAECOLOGY    IN   THE    UNIVERSITY    OF    VERMONT;    FELLOW 

OF  THE  AMERICAN  ASSOCIATION  OF  OBSTETRICIANS  AND  GYNECOLOGISTS  ; 

SURGEON    TO    THE    SAMARITAN     HOSPITAL,    TROY,    NEW    YORK 


WITH  AN  INTRODUCTION  BY  PROF.  KEHR 


PHILADELPHIA 
P.    BLAKISTON'S    SON    &    CO. 

IOI2     WALNUT     STREET 
I  90  I 


Copyright,  1901,  by  WILLIAM  WOTKYNS  SEYMOUR 


PRESS    OF 

Shermajt  &  Co.,  Phxe^dei-phia 


WX 

7SS 
l^0\ 


TRANSLATOR  S    DEDICATION 
TO    THE    MEMORY    OF    MY    FATHER 

WILLIAM  PIERCE  SEYMOUR,  A.B.,  WILLIAMS,  M.D.,  UNIV. OF  PENNA. 

1825— 1893 

A   RARE   PRACTITIONER,    AN   ACCOMPLISHED    OBSTETRICIAN 

HE  ADVOCATED  OPERATION  FOR  TYPHLITIS  IN  1 85 7  : 

FOR   A   GENERATION    TAUGHT    THE    INFECTIOUS    NATURE   OF    PNEUMONIA  : 

THAT    A   VISIBLE    MEMBRANE    WAS     NOT     ESSENTIAL     TO     THE     MALIGNANCY     OF 

DIPHTHERIA  OR  ITS  DISTRIBUTION,  AND  WHILST  PROF.  OF  OBSTETRICS 

AT   UNION    UNIVERSITY    TAUGHT    THE    EXISTENCE 

OF   THREE   PHYSIOLOGICAL   PLANES    IN    THE   OBSTETRIC    PELVIS  : 

THE   PLANES    OF    ENTRANCE,    ROTATION 

AND   THE    PLANE   OF   THE   ARCH 


782S31 


TRANSLATOR'S  PREFACE. 


The  translator  has,  from  the  time  of  Tait's  first  operation,  had 
a  decided  interest  in  gallstone  surgery,  which  was  increased  by 
some  personal  operations  in  that  field.  It  was  his  painful  ex- 
perience to  himself  develop  gallstone  disease,  which  plagued  him 
several  years,  and  caused  a  still  more  lively  interest  in  the  treat- 
ment of  cholelithiasis,  especially  the  various  operations  for  its 
relief.  The  tortures  became  so  severe  and  the  attacks  so  fre- 
quent that  his  professional  work  was  done  only  under  the  great- 
est exercise  of  will  power,  and  he  was  constantly  pursued  by  the 
fear  of  morphinism  or  a  break-down  in  middle  life.  In  Novem- 
ber, 1889,  he  underwent  a  cholecystostomy  at  the  hands  of  Mr. 
Lawson  Tait,  with  a  complete  restoration  to  health.  Since  then 
he  has  frequently  advised  operation  for  gallstone  disease,  and  has 
himself  in  all  done  30  operations,  with  2  deaths.  This  includes 
5  cases  of  stones  in  the  common  duct,  2  lithotripsies  and  3  chole- 
dochotomies,  which  have  all  recovered.  Gallstone  surgery  has 
not  received  in  America  the  acceptation  which  it  deserves.  Not 
but  that  in  McBurney,  Richardson  and  others  we  have  as  good 
operators  as  exist  anywhere,  but  because  the  large  majority  of 
the  profession  still  cherish  the  delusion  that  gallstones  can  be 
dissolved,  and  regard  at  best  operations  for  gallstone  disease  as 
a  last  resort.  The  works  accessible  to  the  general  practitioner 
are  written  either  from  the  standpoint  of  the  internist,  who  still 
believes  operation  to  be  a  last  resort,  or  from  the  standpoint  of 
the  operating  surgeon  who  devotes  more  attention  to  the  tech- 
nique of  the  different  operations  than  to  the  diagnosis  of  the 
various  forms  of  gallstone  disease.  It  is  the  very  great  merit  of 
Professor  Kehr's  book  that  it  discusses  fairly  and  thoroughly  the 

(  vii  ) 


viii  TRANSLATOR'S  PREFACE. 

nature  of  the  many-sided  gallstone  disease,  particularly  its  dif- 
ferential diagnosis,  and  bases  its  surgical  treatment  upon  the  facts 
learned  by  an  unrivalled  experience  at  the  operating  table.  He 
who  carefully  reads  what  Professor  Kehr  has  written  cannot  fail 
to  become  a  better  diagnostician  of  this  disease,  which  too  often 
now  remains  years  long  unrecognized,  to  the  suffering  and  loss 
of  the  patient.  The  results  attained  by  experienced  operators 
in  this  field  are  such  that  the  dangers  of  early  operation  are  as 
nothing  compared  with  the  tortures,  loss  of  working  capacity 
and  danger  to  life  associated  with  the  disease.  The  labor  of 
translation  has  been  a  labor  of  love,  and  I  trust  that  in  its  English 
garb  it  may  prove  helpful  to  many  who  may  become  propagan- 
dists in  the  field  of  gallstone  surgery. 

Troy,  New  York,  February,  1901. 


PROF.  KEHR'S  INTRODUCTION  FOR  THE 
AMERICAN  TRANSLATION. 


Professor  Seymour  has  in  an  amiable  manner  desired  me, 
in  an  introduction  to  this  translation  of  my  "  Diagnosis  of  Gall- 
stone Disease,"  to  give  a  brief  resume  of  the  results  attained  by 
my  gallstone  operations.  To  this  I  heartily  accede.  Until  the 
present  (on  the  25th  of  November,  1900)  I  have  had  547  gall- 
stone operations,  and  have  thus,  of  all  living  surgeons,  done  the 
most  gallstone  operations.  The  number  is  not  so  important ; 
the  results  are  the  chief  thing,  and  of  them  I  can  report  the  fol- 
lowing : 

After  204  conservative  operations  on  the  gall-bladder  (cystos- 
tomies,  cystocotomies,  cystendyses)  I  had  4  fatal  results,  whilst 
of  121  cystectomies  4,  and  of  97  choledoehotomies  or  hepaticus 
drainage  cases  6  pursued  a  fatal  course.  Of  gallstone  disease 
complicated  with  carcinoma  of  the  liver,  of  the  gall-bladder,  of 
the  choledochus  or  the  pancreas,  or  if  there  existed  diffuse  puru- 
lent cholangitis,  peritonitis  or  cirrhosis  of  the  liver,  then  the 
mortality  rose  to  47  per  cent. 

If  one  excludes  these  cases,  against  which  every  sort  of  treat- 
ment is  absolutely  powerless,  then  there  are  422  gallstone  lapa- 
rotomies and  14  deaths  ;   3.3  per  cent,  mortality. 

Among  the  fast  35  choledoehotomies  or  hepaticus  drainage 
cases  I  have  had  no.  deaths  to  bemoan,  which  is  to  be  regarded 
as  the  direct  consequcirce  of  the  operative  procedure  itself. 

The  more  one  operates,  so  much  the  more  certain  does  one 
learn,  naturally,  to  master  the  technique. 

Choledoehotomies,  for  which  I  formerly  required  two  or  three 

(ix) 


X  PROF.   KEHR'S  INTRODUCTION. 

hours,  I  now  complete  in  a  half  hour,  and  an  easy  cystectom}^  I 
do  now  frequently  in  ten  minutes. 

My  statistics  are,  as  also  Dr.  Muller  of  W'urzburg  makes 
conspicuous  in  an  article,  well  worth  reading,  in  the  Wurzburg 
Transactions,  "  Gallstone  Disease  and  its  Treatment,"  on  this  ac- 
count very  instructive,  in  that  the  simple  operations  involving  the 
gall-bladder  almost  always  ran  a  favorable  course,  and  even  dif- 
ficult choledochotomies  show  a  relatively  small  mortality  of  6  per 
cent.,  whilst  in  the  protracted  cases,  in  which  (unfortunately 
often  by  protracted  internal  treatment)  peritonitis,  cirrhosis  of 
the  liver,  cholangitis,  perforative  processes,  carcinoma  of  the 
gall-bladder  had  developed,  we  were  far  too  frequent!}*  reminded 
of  the  impotence  of  surgical  skill.  Therefore  it  is  most  fitting 
to  operate  when  the  stones  still  remain  in  the  gall-bladder,  and 
not  to  dawdle  with  operative  interference  until  the\'  reach  the 
deep  ducts.  This  requirement  will  onh'  seldom  be  followed.  So 
long  as  cholelithiasis  is  limited  to  the  gall-bladder,  a  positive  di- 
agnosis is  always  for  the  experienced  no  easy  matter,  and  then  it 
is  implanted  in  the  nature  of  man  that  the  patient,  in  his  dread  of 
knife  and  narcosis,  should  submit  himself  more  readily  to  a  Carls- 
bad cure  than  to  an  operation.  When,  however,  what  I  expect, 
the  special  diagnosis  of  cholelithiasis  will  be  so  much  further 
advanced  than  heretofore,  and  the  astounding  results  of  gallstone 
surgeons  shall  become  still  better  known,  then  will  doctors  earlier 
advise  operation,  and  then  will  this  branch  of  the  operative  heal- 
ing art  develop  into  a  magnificent  fruition  and  bear  many  beauti- 
ful fruits. 

Since  the  publication  of  this  book,  in  the  summer  of  1899, 
that  is  in  the  course  of  one  and  a  half  years,  I  have  done  113 
further  gallstone  laparotomies.  With  reference  to  the  indications 
for  operation,  I  have  introduced  no  notabl-j  changes.  In  the 
selection  of  operative  methods  I  have  emrployed  more  and  more 
the  cystectomy  in  combination  with  hepaticus  drainage.  If  I  am 
compelled  to  appeal  to  the  knife  in  an  acute  attack  (in  serous  or 
purulent  cholecystitis),  then  I  give  the  preference  to  cystostomy. 


PROF.  KEHR'S  INTRODUCTION.  xf 

the  formation  of  a  fistula.  If  I  operate  in  the  free  interval,  then 
I  extirpate  the  gall-bladder,  open  up  the  cysticus  and  choledo- 
chus,  and  finally  drain  the  hepaticus.  Only  in  this  manner  will 
we  avoid  with  certainty  true  and  false  recurrences.  Concerning 
this  very  important  point,  I  have  sufficiently  expressed  myself  in 
three  very  recently  appearing  articles  : 

1.  "  What  is  the  Proportion  of  Recurrences  after  our  Gallstone 
Operations?"  Von  ha.ngenheck's  A  rc/iivf.  Klin.  Chir.,  6i  Band. 
Heft  2. 

2.  "  Concerning  Recurrences  after  Gallstone  Operations." 
Berlin  Klinik,  1899,  October. 

3.  Contributions  to  Abdominal  Surgery^  with  Especial  Atten- 
tion to  Eighty-four  Gallstone  Laparotomies  done  in  the  Past 
Year."      Berlin,  1900.      Fischer's  Med.   Verlag. 

These  last  contributions  form,  in  a  way,  a  continuation  of  the 
introduction  to  the  learning  of  the  diagnosis  of  the  separate  forms 
of  gallstone  disease.  May  the  translation  of  Professor  Seymour, 
whom  I  heartily  thank  for  the  friendly  interest  shown  in  me  and 
my  book,  contribute  to  gallstone  surgery  finding  in  America 
the  same  extension  as  is  the  case  to-day  in  Germany.  There  still 
is  in  the  entire  capital  surgery  no  field  in  which  the  operator  can 
attain  such  brilliant  results  and  earn  so  many  thanks  as  in  the 
field  of  gallstone  operations. 

Prof.  Hans  Kehr. 

Halberstadt,  26  November,  1900. 


TABLE  OF  CONTENTS. 


PART  I. 

PAGE 

Lecture  I. — The    Pathology    and   Pathological  Anatomy  of  Chole- 

LiTHiASLs, .19 

On  the  general  and  special  diagnosis  of  gallstone  disease,  19  ;  the  latency  of 
cholelithiasis,  25  ;  cholecystitis,  26  ;  Naunyn's  views  of  gallstone  colic,  27  ; 
the  different  forms  of  cholecystitis,  28  ;  Riedel's  foreign  body  inflammation, 
28  ;  pathologico-anatomical  condition  in  cholecystitis,  30 ;  hydrops  of  the 
gall-bladder,  31  ;  spontaneous  cure  of  cholecystitis,  32;  conception  of  a 
cure  of  cholecystitis,  33-35  ;  pericholecystitis,  36 ;  peripyloritis,  37  ;  fistula 
formation  between  gall-bladder  and  the  hollow  organs  of  the  abdomen,  38 ; 
Contraction  processes  in  the  gall-bladder,  condition  of  liver  in  cholecystitis, 
absence  of  jaundice,  39  ;  Riedel's  lobe,  39  ;  different  forms  of  jaundice,  in- 
flammatory, true  lithogenous  and  functional,  41,  42;  stones  in  the  common 
duct,  44  ;  thrombophlebitis  and  cholangitis,  44 ;  sepsis,  pyaemia,  carcinoma 
of  the  gall-bladder,  45,  46  ;  the  pathological  anatomy  is  the  foundation  for 
the  special  diagnosis  and  treatment  of  gallstone  disease,  48. 

Lecture  II. — The  Amnesis  and  Examination  in  Cholelithiasis,  .         .     50 

The  importance  of  an  exact  amnesis,  50 ;  attention  to  age  and  sex,  52 ;  the 
diseases  of  parents,  brothers  and  sisters,  52  ;  to  the  previous  illness  of  the 
patient,  52  ;  to  the  character  of  the  pain,  53  ;  to  the  occurrence  of  jaundice, 
53 ;  to  fever,  54  ;  to  the  condition  of  the  stomach,  54 ;  to  the  condition  of 
the  bowels,  54  ;  to  the  bodily  weight,  55  ;  to  the  appearance  of  nervous 
symptoms,  55;  to  the  use  of  morphine,  56;  the  examination  of  gallstone 
patients,  56  ;  general  examination,  57  ;  special  examination,  59  ;  inspection, 
59  ;  palpation,  60  ;  percussion,  63  ;  auscultation,  63  ;  exploratory  puncture, 
64 ;  anaesthesia,  64  ;  Rontgen  ray  examination,  65  ;  examination  of  the 
blood,  65. 

Lecture  III. — The  Special  Diagnosis  of  Cholelithiasis,       .         .        .     67 

The  different  kinds  of  pain  in  cholelithiasis,  67  ;  most  gallstone  colics  the 
evidence  of  inflammation,  67  ;  with  stones  in  the  gall-bladder  the  pain  is 

(  xiii  ) 


xiv  TABLE  OF  CONTENTS. 


PAGE 


mostly  in  the  right  hypochondrium,  68  ;  variability  of  the  pain  according  to 
the  location  of  the  stones,  68  ;  difficulty  of  distinguishing  ulcer  ventriculi 
from  gallstones  by  the  pain,  68  ;  ulcer  of  stomach  difficult  to  demonstrate 
during  a  gallstone  operation,  69  ;  localization  of  pain  in  gallstones  and  ulcer 
of  the  stomach,  71  ;  cramps  of  the  stomach  usually  due  to  gallstone  cohc, 
72  ;  pathological  anatomy  of  appendicitis  and  cholecystitis  similar,  73  ;  in- 
testinal cohc,  73  ;  ileus,  73  ;  liver  cohc  of  nervous  origin  doubtful,  74  ; 
peritonitis,  74  ;  renal  colic,  74 ;  syphilis  of  the  Hver,  75  ;  gastric  crises  of 
locomotor  ataxia,  75  ;  hernia  of  the  linea  alba,  75  ;  pancreatic  cohc,  76  ; 
pancreatic  cysts,  77  ;  characteristics  of  gall-bladder  tumors,  78,  79  ;  typical 
cholecystitis,  79 ;  differential  diagnosis  of  gall-bladder  tumors  and  tumors  of 
pylorus,  colon,  etc.,  80;  from  right-sided  movable  kidney,  81  ;  acute  ob- 
struction of  the  common  duct,  82  ;  table  in  which  the  typical  groups  of  gall- 
stone disease  are  shown,  84,  85,  86  ;  on  the  use  of  the  table,  87  ;  explana- 
tion of  the  table,  89  ;  chronic  obstruction  of  the  choledochus  by  stone,  90  ; 
differentiation  of  chronic  obstruction  by  stone  and  cancer,  91  ;  the  difficulty 
of  anatomical  diagnoses  in  certain  cases,  94  ;  fistulous  communications,  94 ; 
Naunyn's  classification  of  gallstone  disease,  97  ;  Kehr's  classification,  97, 
q8:  Riedel's,  98. 


Lecture  IV. — The  Treatment  of  Cholelithiasis, 

Frequency  of  gallstone  disease,  99  ;  latency  of  gallstones,  99  ;  two  methods 
of  treatment,  Carlsbad  cure  and  operation,  99 ;  no  solvent  for  stones  exists, 
100  ;  cholagogues,  100  ;  the  aim  of  internal  treatment  to  bring  about  latency, 
loi  ;  effect  of  Carlsbad  springs,  loi  ;  von  Winiwarter  and  Kraus  as  to  the 
indications  for  operation,  102  ;  results  from  various  operations,  103  ;  results 
improve  with  experience,  105  ;  operations  in  two  stages  to  be  decried,  105  ; 
sutures  causing  recurrences,  105  ;  conception  of  early  operation,  106  ;  the 
slight  danger  of  early  operation  bears  no  sort  of  relation  to  the  danger  of  the 
disease  itself,  107  ;  at  Carlsbad  mostly  mild  cases  come  under  observation, 
107  ;  Naunyn's  regular  and  irregular  forms  of  gallstone  disease,  108  ;  Fiir- 
bringer  regards  cholelithiasis  as  a  grave  disease,  109;  Naunyn's  clinical 
material  and  his  views  of  the  disease,  iio;  indications  for  a  Carlsbad  cure, 
114;  indications  for  operation,  115;  the  foundation  for  these  views,  117; 
operation  unnecessary  in  acute  obstruction  of  the  choledochus,  121  ;  opera- 
tion in  all  cases  of  cholecystitis  cholangitis  acutissima,  121  ;  operation  less 
dangerous  in  all  suppurative  processes  in  the  abdomen  than  expectant  treat- 
ment, 122;  adhesions,  125  ;  expl orator)' operation,  125  ;  treatment  of  chronic 
recurring  cholelithiasis,  127  ;  treatment  of  chronic  obstruction  of  the  chole- 
dochus by  stone,  129;  morphinism  an  indication  for  operation,  130. 


TABLE  OF  CONTENTS.  XV 


PART  II. 


INE  Hundred  Clinical  and  Operation  Histories,  of  which  the  Close 
Study  Assists  Greatly  in  Learning  the  Special  Diagnosis  of 
Cholelithiasis, 


introduction,  author's  results  in  409  gallstone  operations, 

3ught  the  practicing  physician  do  gallstone  operations,    .... 

1.  Stones  in  the  gall-bladder  with  normal  or  but  slight'y  altered  walls.     Cystic 

duct  patent.      Contents  clear  bile.     No  adhesions,  ... 

2.  Stones  in  the  already  often  inflamed   gall-bladder.      Cystic   duct  patent, 

Contents  pure  or  but  little  altered  bile.      Adhesions,        ... 

3.  No  stones  in   the   gall-bladder.      Cystic  duct  patent.      Contents  pure  bile 

Adhesions,  .......... 

4.  Acute  cholecystitis  in  a  relatively  but  little  altered  distjnsible  gall-bladder 

5.  Acute  cholecystitis  in  contracted  gall-bladder,  .... 

6.  Hydrops  chronicus  cystidis  felleee,   ....... 

7.  Empyema  chronicum  cystidis  fellece,         ...... 

8.  Carcinoma  of  the  gall-bladder,         ....... 

9.  Acute  obstruction  of  the  choledochus  by  stone,  .  .  .  , 
iO.    II.   Chronic  obstruction  of  choledochus  by  stone,      .... 

2.  Chronic  obstruction  of  choledochus  by  tumor,  .... 

3.  Inflammatory  or  lithogenous  jaundice,      ...... 

4.  Stomach  or  gall-bladder  or  both  affected,  ..... 

5.  Gallstone  ileus,        .......... 

6.  The  difficulty  and  impossibility  of  special  diagnoses  in  certain  cases. 


APPENDIX. 


135 

135 
136 


141 

150 

159 
169 
196 
204 
220 
225 
230 
231 

273 
288 

293 
308 

3" 


riie  18  gallstone  operations  done  by  the  author  between  April  I  and  May  15, 
1899,  with  remarks  concerning  Riedel's  inflammatory  jaundice  and  in- 
sidious infection  of  the  biliary  system,   .  .  .  .  .  .  -329 


PART 


17 


THE 

Diagnosis  of  the  Separate  Forms 

OF 

Gallstone  Disease. 


LECTURE   I. 

THE  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY 
OF  CHOLELITHIASIS. 

Gentlemen  :  Already  very  often  in  numerous  works  concern- 
ing the  surgical  treatment  of  gallstone  disease  have  I  given 
expression  to  my  conviction  that  the  diagnosis  of  cholelithiasis  is 
full  of  deceptions.  We  doctors  are  contented  for  the  most  part 
with  the  general  diagnosis  of  gallstones,  without  determining 
their  manifold  expressions,  the  degree  of  inflammation  and  the 
location  of  the  stones.  Special  diagnoses,  according  to  my  ex- 
perience gained  from  409  gallstone  operations  performed  by  me, 
are  very  seldom  made. 

How  is  this  fact,  which  none  can  deny,  to  be  explained,  and 
what  means  have  we  at  hand  to  learn  the  special  diagnosis  of 
gallstone  disease  ?  May  I  be  permitted  at  the  outset  to  briefly 
answer  these  two  questions. 

Whoever  wishes  to  review  and  recognize  a  disease  must  first 
of  all  apply  himself  to  the  study  of  its  pathological  anatomy  with 
all  the  means  which  are  at  his  command.  Diagnostic  acumen, 
the  finest  perceptive  powers,  experience  and  practice  are  qualities 

19 


20  GALLSTONE  DISEASE. 

and  gifts  of  the  doctor  which  are  not  to  be  underestimated,  yet 
they  avail  him  nothing  if  his  knowledge  of  the  pathological  pro- 
cesses under  which  the  disease  processes  develop  are  hazy  and 
defective.  Unfortunately  for  the  practitioner  of  internal  medi- 
cine, the  study  of  these  processes  as  they  develop  in  gallstone 
disease  is  extraordinarily  impeded,  since  he  is  for  the  most  part 
thrown  upon  his  observations  at  the  bedside  and  the  autopsy 
table.  And  what  country  or  city  practitioner  can  read  all  the 
countless  surgical  publications,  which,  above  all,  usuall)'  treat 
much  more  of  the  technical  rather  than  the  pathologico-ana- 
tomical  questions  ?  In  addition,  the  older  doctors  scarcely  ever 
have  been  present  at  the  university  at  a  gallstone  operation,  and 
of  the  younger  only  a  very  few  have  now  and  then  seen  a  gall- 
stone removed  by  surgical  means.  This  is  the  reason  why  the 
majority  of  doctors  fail  to  recognize  all  the  changes  which  gall- 
stones produce  in  the  living,  and  since  they  are  not  masters  of 
the  pathology  or  pathological  anatomy  of  cholelithiasis,  its  special 
diacrnosis  remains  for  them  an  unsolved  riddle.  On  the  other 
hand,  for  us  surgeons  who  have  the  good  fortune  of  following 
the  pathological  anatomy  of  gallstone  disease  in  its  different 
phases  by  the  instruction  which  comes  through  seeing  numerous 
autopsies  in  vivo,  of  studying  the  processes  and  of  being  able  to 
prove  the  obstruction  of  the  stones,  the  learning  of  the  special 
diagnosis  will  accordingly  be  easily  acquired.  With  our  eyes 
we  see  in  the  opened  abdomen  the  manifold  changes  and  ravages 
wrought  by  gallstones,  we  convince  ourselves  of  the  size  and 
form  of  the  liver  and  the  gall-bladder,  and  whatever  remains  con- 
cealed from  our  vision  is  felt  by  our  hand,  which,  with  sufficient 
practice,  no  stone  or  adhesion  very  easily  escapes.  With  the  knife 
we  open  into  the  inflammed  gall-bladder,  and,  thanks  to  asepsis, 
we  need  not  shy  at  laying  free  and  opening  up  the  cystic  and 
common  ducts.  Indeed,  I  have  myself  by  seven  cases  of  drain- 
age of  the  hepatic  duct  furnished  the  proof  that  we  need  not  fear 
to  introduce  the  irrigation  catheter  and  finger  into  the  gall  ducts 
of  the  liver.     Before  we  enter  upon  such  operations  we  frame  our 


PATHOLOGY  OF  CHOLEUTITIASIS.  21 

diagnosis  by  the  amncsis,  inspection  and  examination.  I  have 
always,  consequently,  held  fast  to  this  :  that  it  did  not  simply  con- 
cern gallstones,  but  that  it  considers  the  pathologico-anatomical 
forerunners  which  are  hidden  from  us,  the  seat  of  the  stones  and 
the  degree  of  inflammation.  If  you  take  in  hand  the  clinical 
histories  written  dow^n  by  my  assistants  and  me,  you  must  come 
to  the  conviction  that  I  was  moved  to  perfect  to  the  utmost  the 
special  diagnosis  of  gallstone  disease.  Here  is,  for  example, 
gallstones  in  undistended  gall-bladder  with  patent  cystic  duct ; 
there,  chronic  obstruction  of  the  common  duct  by  stones,  gall- 
bladder contracted  ;  with  the  third  patient  the  diagnosis  is  acute 
purulent  cholecystitis  and  local  peritonitis  ;  in  the  fourth,  dropsy 
of  the  gall-bladder  ;  in  the  fifth,  acute  obstruction  of  the  common 
duct ;  in  the  sixth  case  I  assumed  a  chronic  obstruction  of  the 
common  duct  by  a  tumor  of  the  pancreas  ;  in  the  seventh,  adhe- 
sive peritonitis  of  the  gall-bladder,  probably  without  the  forma- 
tion of  stones  ;  in  the  eighth  I  guessed,  together  with  old  inflam- 
matory processes  in  the  gall-bladder,  an  ulcer  or  a  cancer  of 
the  stomach.  If,  then,  by  reason  of  such  a  diagnosis  in  this  or 
that  case,  the  abdomen  was  opened,  it  was  then  easy  by  exact 
and  careful  examination  of  the  operation  field  to  determine 
whether  or  not  my  diagnosis  was  correct.  If  it  was  wrong,  then 
I  took  pains  in  my  next  cases  to  shun  the  error,  and  so  I  learned 
gradually  to  avoid  errors  in  diagnosis,  and  attained  in  time,  in  the 
weighing  of  the  diagnostic  factors,  to  an  accuracy  which  the  in- 
ternist naturally  can  never  reach.  If,  moreover,  the  latter  has 
the  opportunity  frequently  to  follow  the  practice  of  the  gallstone 
surgeons,  and  to  be  present  at  their  operations,  then  he  also 
learns  the  special  diagnosis  of  gallstone  disease.  Several  col- 
leagues of  my  section,  who  have  sent  their  patients  to  my  clinic 
and  have  been  present  at  the  operations,  have  become  in  this 
manner  very  excellent  gallstone  diagnosticians,  and  I  always 
have  great  pleasure  if  the  relatives  who  bring  the  patient  give 
me  a  letter  from  the  doctor  in  which,  with  great  exactness,  the 
special  form  of  gallstone  disease  is  diagnosticated. 


22  GALLSTONE  DISEASE. 

Of  course  errors  occur  frequently  enough  !  Even  the  most 
experienced  gallstone  surgeon  will  not  always  hit  the  mark,  and 
when  to-day  I  glance  over  the  great  number  of  my  cases,  many 
a  one  comes  to  mind  in  which  I  have  greatly  erred  ;  it  would  be 
folly  and  presumption  not  to  admit  it.  I  have  in  truth  learned 
more  from  two  wrong  diagnoses  than  from  twenty  correct  ones, 
and  I  am  of  the  conviction  that  the  physician  does  not  at  all  com- 
promise himself  by  openly  confessing  his  error.  Our  ability  (to 
relieve)  often  remains  far  behind  our  wish  ;  and  since  our  knowl- 
edge is  fragmentary,  since  cholelithiasis  must  be  regarded  in  every 
relation,  also  in  its  symptoms,  as  an  incalculable  disease,  I  will 
yet  make  errors  in  diagnosis,  even  though  I  may  have  done  thou- 
sands of  gallstone  operations.  Errors  in  diagnosis  occurred  not 
infrequently  in  my  first  hundred  cases,  but  their  number  steadily 
diminished  ;  and  with  increasing  experience,  I  can  truly  say  with 
almost  daily  experience,  I  have  previous  to  operation  in  the  last 
one  hundred  cases,  with  very  few  exceptions,  made  an  exact 
diagnosis  of  the  condition  which  awaited  me. 

An  exact  amnesis,  a  most  minute  inquiry  into  the  course  of 
the  disease,  a  thorough  inspection  and  physical  examination  con- 
jure up,  as  it  were,  before  my  mind  all  the  precursors  as  they 
have  developed  behind  the  abdominal  wall  in  the  hidden  depths 
of  the  belly.  Whether  stones  lie  in  the  gall-bladder,  the  cystic 
or  the  common  ducts  ;  whether  they  are  quiescent  or  movable  ; 
whether  the  gall-bladder  is  contracted  or  enlarged  ;  whether  it 
contains  bile,  serum  or  pus  ;  whether  adhesions  have  formed 
between  bile-ducts  and  omentum,  intestine  or  stomach,  or  whether 
perforative  accidents  have  occurred,  all  these  processes  we  can 
diagnosticate  with  considerable  certainty.  I  will  endeavor  so 
far  as  I  can,  in  what  follows,  to  picture  the  special  diagnosis  of 
gallstone  disease  so  as,  in  connection  with  it,  to  answer  the  two 
principal  questions  which  most  concern  the  practising  physician  : 

1.  In  what  cases  of  cholelithiasis  is  an  operation  indicated;  and 

2.  When  should  one  send  gallstone  patients  to  Carlsbad? 
Especially  upon  the  basis  of  the  pathologico-anatomical  con- 
ditions which  I  have  met  in  my  numerous  operations,  will  I  dis- 


PATHOLOGY  OF  CHOLELITHIASIS.  23 

CUSS  in  detail  the  diagnosis  of  gallstone  disease,  and  for  the  better 
understanding  and  for  the  justification  of  my  assertions  will 
report  a  series  of  clinical  histories  without  intending  to  enter  into 
the  technique  of  the  operation.  Whoever  may  wish  to  inform 
himself  in  this  respect  I  would  refer  to  my  former  contributions  ;  * 
the  following  explanations  are  intended  solely  for  the  practising 
physician,  on  whose  framing  of  diagnosis  and  its  indications  the 
welfare  or  misery  of  the  gallstone  patients  for  the  most  part 
depends.     With  no  disease  has  the  old  proveb  Qui  bene  dignoscit 

*  {a)  "  Report  upon  197  Gallstone  Operations  of  the  Last  Two  and  Two-thirds 
Years." — Archiv  fiir  Klin.  Chirurgie,  58  Bd.,  Heft  3. 

[b^  "  How,  in  what  Manner  and  in  what  Cases  of  Cholelithiasis  does  a  Carlsbad 
Cure  Act,  and  Why  are  the  Views  of  the  Surgeon  and  Carlsbad  Practitioner  in  Rela- 
tion to  the  Prognosis  and  Treatment  of  Cholelithiasis  so  Different?" — Miinch.  Med. 
Wochenschrift,  1898,  No.  38. 

(r)  "The  Results  of  360  Gallstone  Laparotomies,  with  Especial  .Vttention  to  the 
151  Operations  done  in  the  Last  Two  Years." — Samml.  Klin.  Vortrage  Von  Volk- 
mann,  No.  225,  Oct.,  1898. 

{d^  '*The  Treatment  of  Calculous  Cholangitis  by  Direct  Drainage  of  the  Hepatic 
Duct." — Miinch.   Med.  Wochenschr.,  1897,  No.  41. 

((?)  "The  Surgical  Treatment  of  Gallstone  Disease.  Berlin,  1896." — Fischer's 
Med.  Verlag.  (H.  Kornfeld). 

(/)  "A  Review  of  209  Gallstone  Laparotomies,  with  Special  Attention  to  Certain 
Elsewhere  Seldom  Observed  Difficulties  in  30  Choledochotomies." — Archiv  f.  Klin. 
Chirurgie,  Bd.  53,  Heft  2. 

iyg)  "The  Removal  of  the  Impacted  Gallstone  from  the  Cystic  Duct  by  Incision 
of  this  Duct." — Archiv  f.  Klin.  Chirurgie,  Bd.  48,  Heft  3  (Chir.  Congr.,  1894), 
and  Berl.  Klin.  Wochenschr.,  1894,  p.  536. 

(/^)  " New  Experiences  in  the  Field  of  Gallstone  Surgery." — Berl.  Klin.,  Heft 
78,  Dec,  1894. 

(z)  "On  the  Surgery  of  Gallstone  Disease." — Deutsche  Zeitschr.  f.  Chir.,  j8  P5d. , 
p.  321,  1894. 

(-^)  "On  the  Surgery  of  Gallstone  Disease." — Berl.  Klin.  Wochenshcrift,  1893, 
No.   2. 

(/)  "  Concerning  a  vShot  Wound  of  the  (iall-Bladder  Cured  by  an  Ideal  Cholccys- 
tostomy." — Centralblatt  fur  Chir.,  1892,  No.  31. 

[ni)  Operative  Contribution  to  the  Essay  of  Dr.  Hochhaus  in  No.  17  of  this  weekly, 
"Concerning  Dilation  of  the  Stomach  and  Duodenal  Stenosis." — Berlin  Klin. 
Wochenschr.,  1891,  No.  22.  ^ 

(«)  "  Upon  the  Surgery  of  the  Gall-Bladder."  Address  before  the  Arzte-Verein 
of  the  Government  district  of  Magdeburg,  Oct.  20,  1891. 


24  GALLSTONE  DISEASE. 

bene  curat  such  a  pregnant  meaning  as  in  cholelithiasis.  For 
whoever  can  make  good,  that  is,  special  diagnoses  in  gallstone 
disease,  whoever  has  learned  to  differentiate  hydrops  from 
empyema,  cholecystitis  from  cholangitis,  for  him  it  will  not  be 
difficult  to  determine  that  this  patient  should  go  to  Carlsbad 
and  that  to  a  surgical  clinic. 

The  ic'tV/r///'/;/^ there  requires  the  hot  wonder-working  Sprudel 
and  here  a  sure  asepsis  and  a  perfect  technique.  Of  course  our 
results  will  remain  few  and  bad  if  we  are  only  entrusted  with  the 
treatment  of  desperate  and  late  recognized  cases  of  purulent 
cholangitis  and  perforative  peritonitis.  No  one  has  it  more  in 
his  power  to  increase  the  fame  of  surgical  ability  and  science 
than  the  practising  physician  as  soon  as  he  early  makes  correct 
diagnoses,  and,  when  not  too  late,  turns  over  his  gallstone  cases 
to  the  aseptic  scalpel  of  the  surgeon. 

Whoever  wishes  to  learn  the  special  diagnosis  of  cholelithiasis 
must  know  accurately  its  pathology.  This  requisite,  which  I 
have  already  before  expressed,  is  as  necessary  and  as  true  as 
the  proverb,  '*  Whoever  wishes  to  learn  to  swim  must  go  into 
the  water."  Permit  me,  first  of  all,  briefly  to  picture  to  you  the 
pathological  changes  which  gallstones  produce.  I  base  myself 
in  this  really  upon  the  operative  conditions  which  I  have  met  in 
my  gallstone  operations,  and  I  can  truly  assert  that  every  patho- 
logical process  occasioned  by  gallstones  has  come  under  my 
eyes  and  hands.  First  of  all,  it  is  to  be  insisted  upon  that  most 
gallstones  originate  in  the  gall-bladder.  In  the  bile-ducts  their 
primary  origin  is  extraordinarily  rare.  To  say  anything  con- 
cerning the  formation  of  the  concretions  cannot  be  my  task  at 
this  time.  It  is  a  well-known  fact  that  gallstones,  even  when 
they  in  thousands  lie  together  in  the  gall-bladder,  need  not 
occasion  any  discomfort.  If  the  cystic  duct  is  patent  the  bile 
flows  unhindered  in  and  out,  and  so  the  stones  lie  quiet  and  still  in 
their  house,  as  harmless  foreign  bodies,  and  for  a  time  are  not  to  be 
feared.  In  fact,  during  the  examination  of  the  abdomen  of  elder 
women,  one  stumbles  not  so  infrequently  upon  an  enormous  stone 


PATHOLOGY  OF  CHOLELITHIASIS.  2$ 

tumor  of  the  gall-bladder  which  on  palpation  grates  and  cracks  as 
if  one  pounded  a  sack  of  nuts,  without  that  the  bearer  complains 
of  any  sort  of  discomfort.  Gallstones  are  so  frequent — almost 
every  tenth  adult  body  exhibits  them — that,  as  a  surgeon  point- 
edly says,  every  "theater,  every  church,  every  concert-hall 
would  resound  with  lamentation,  if  stones  occasioned  discom- 
fort in  all  cases."  Only  about  5  per  cent,  of  gallstone  subjects  feel 
anything  of  the  presence  of  the  unbidden  guests,  and  95  per 
cent,  remain  at  least  from  severe  suffering  entirely  free.  If,  with 
Riedel,  we  assume  that  in  the  German  empire  alone  2  millions 
have  gallstones,  then  indeed  only  100,000  feel  anything  of 
their  stones,  whilst  1,900,000  remain  exempt  from  pain.  They 
have,  perhaps,  sometime  some  dragging  in  the  right  side,  they 
feel  a  slight  oppression  in  the  stomach,  suffer  from  eructations 
and  occasional  anorexia,  but  on  the  whole  there  is  no  question 
of  actual  disease.  The  gynecologist,  who  for  the  doing  of  an 
ovariotomy  opens  the  belly,  frequently  finds,  if  he  introduces  his 
hand  into  the  right  upper  abdomen,  the  gall-bladder  full  of 
stones,  and  if  he  later,  after  a  successful  operation,  asks  the  pa- 
tient whether  she  has  not  had  now  and  then  discomfort  in  the 
stomach  or  a  real  attack  of  colic,  he  will  almost  invariably  re- 
ceive the  reply,  "  I  cannot  remember  that  I  ever  have  felt  pains 
of  that  kind,  my  appetite  has  always  been  good,  vomiting  I  have 
never  had,  and  I  have  felt  absolutely  no  pain  !"  The  reason 
of  this  absolute  latency  of  gallstones  is  the  absence  of  all  in- 
flammation in  and  adhesions  to  the  gall-bladder,  of  changes  in 
the  wall  of  the  gall-bladder  itself,  and  that  upon  which  the  prin- 
cipal emphasis  is  to  be  laid,  that  the  cystic  duct,  the  excretory 
duct  of  the  gall-bladder,  must  almost  always  remain  free  and 
patent.  I  say  intentionally  almost  always,  for  not  so  very  infre- 
quently there  is  absolute  absence  of  discomfort  and  pain  even 
with  an  obstructed  cystic  duct,  with  subsequent  development  of 
a  hydrops  of  the  gall-bladder  of  considerable  extent.  Concern- 
ing this  form  of  cholelithiasis  I  will  speak  later,  and  we  will 
later  learn  to  recognize  the  fact  that   even  with  the  presence  of 


26  GALLSTONE  DISEASE. 

stones  in  the  common  duct  and  in  the  widely  divided  branches 
of  the  hepatic  duct  cholehthiasis  may  run  a  completely  latent  and 
symptomless  course.  Moreover,  stones  may  also  be  present  in 
the  gall-bladder  and  in  the  bile-ducts  without  that  the  patient  is 
at  all  conscious  of  their  presence. 

Something  else  must  be  added  if  the  cholelithiasis  is  to  be 
changed  from  a  latent  to  an  active  condition.  According  to  my 
observations  and  experiences,  this  change  is  caused  in  the  great 
majority  of  cases  by  the  outbreak  of  an  inflammatory  process 
in  the  gall-bladder  itself;  in  a  very  few  by  the  mechanical  ob- 
struction of  the  cystic  duct  by  a  stone,  without  an  inflammation 
preceding  or  being  associated  with  it.  It  is  also  in  fact  the 
cholecystitis,  the  inflammation  of  the  gall-bladder,  which  occa- 
sions the  colic  by  the  distension  and  filling  of  the  hollow^  organ 
and  by  the  excessive  tension  of  its  walls.  The  inflammatory 
process  drives  the  stone  into  the  cystic  duct  ;  there  it  lodges  and 
remains  lying,  if  its  size  precludes  its  continuing  its  progress 
through  the  common  duct  into  the  intestine. 

But  frequently  the  stone  does  not  become  lodged  in  the  neck 
of  the  gall-bladder  or  in  the  cystic  duct.  A  large  stone  lying 
in  the  fundus,  in  spite  of  inflammation  may  not  move  a  milli- 
meter, whilst  the  mucous  membrane  of  the  gall-bladder  swells 
completely  around  it  and  the  cystic  duct  becomes  completely 
obstructed.  And  if,  later,  the  inflammation  subsides,  one  finds  the 
stone  sticking  in  the  same  place,  in  visible  rest.  Of  a  wandering 
of  the  stone,  which  plays  so  prominent  a  part  in  almost  all  text- 
books of  internal  medicine,  there  can  in  such  a  case  be  no 
thought.  Naunyn  himself,  one  of  the  best  diagnosticians  of 
gallstone  disease,  attacks  recently  the  doctrine  of  the  wandering 
of  stones,  in  his  address  before  the  Convention  of  Naturalists  at 
Diisseldorf,  concerning  the  symptoms  of  cholelithiasis  which 
decide  the  indication  to  operation,  by  saying  the  following  : 

**  The  old  theory  according  to  which  the  processes  of  chole- 
lithiasis, especially  of  gallstone  colic,  was  explained,  is  weak — 
for  the  majority  of  cases  false  or  insufficient.     This  theory  was 


PATHOLOGY  OF  CHOLELITHIASIS.  2/ 

^omewhat  as  follows  :  the  gallstones  in  the  gall-bladder  are  wont 
to  become  first  known  when  they  excite  gallstone  colic.  This 
latter  happens  in  this  wise  :  from  some  unknown  reason  one  or 
more  stones  lying  in  the  gall-bladder  enter  the  cystic  duct ;  if 
this  happens,  then  the  stone  is  wont  to  wander  through  the  cystic 
and  common  duct  into  the  duodenum,  and  the  physiological 
and  physical  processes  accompanying  this  wandering  give  rise  to 
the  symptoms  of  colic  ;  the  pains  are  the  expression  of  irritation 
and  violence  which  the  walls  of  the  cystic  and  common  ducts 
endure  from  the  obstructing  stone  ;  the  vomiting,  and  in  part 
the  fever  also,  are  reflex  manifestations,  which  also  are  excited 
by  the  irritation  of  the  mucous  membrane.  The  jaundice  and 
swelling  of  gall-bladder  and  liver  arise  from  the  obstruction  of 
the  bile  excretion  ;  on  this  account  they  first  appear  when  it 
reaches  the  common  duct,  where  alone  it  can  impede  the  excre- 
tion of  bile  from  the  liver.  For  the  swelling  of  the  gall-bladder, 
of  course, — it  has  long  been  known — this  often  does  not  account  ; 
the  gall-bladder  was  also  distended  when  the  stone  lodged  not 
in  the  common  duct,  but  even  in  the  cystic  duct. 

•*  They  imagined  to  explain  this  a  ball-valve  closure  of  the 
cystic  duct ;  the  stone  was  supposed  to  lie  here  so  that  the  bile 
could  still  pass  the  cystic  duct  toward  the  gall-bladder,  while  in 
the  opposite  direction  the  way  was  occluded.  A  similarly  forced 
explanation  another  occurrence  received  :  one  found  that  in 
people  who  had  died  after  severe  gallstone  colic,  the  stone  was 
not  wedged  in  the  bile  ducts,  but  lying  free  in  the  gall-bladder. 
In  this  case  they  assumed  that  the  stone  had  been  wedged  in  the 
cystic  duct,  but  that  finally  it  had  slipped  back  into  the  gall-bladder. 
To-day  we  know  that  something  else  is  the  prime  factor,  namely, 
a  cholecystitis  calculosa.  It  is  almost  difficult  to  understand 
for  how  long  a  time  they  have  overlooked  the  importance  of 
cholecystitis  and  cholangitis  in  cholelithiasis.  To-day  we  know 
what  important  roles  they  play  in  gallstone  disease,  and  therein 
has  the  progress  in  this  domain  been  made."  So  far  Naunyn. 
I  rejoice  that  at   last  the  views  of  the  surgeons  concerning  the 


28  GALLSTONE  DISEASE. 

nature  of  gallstone  colic  attract  the  attention  of  the  internists 
I  personally  had  already  at  the  beginning  of  the  90th  year  with  ^ 
emphasis  indicated  that  almost  all  gallstone  colics  depend  upon 
inflammatory  conditions  of  the  gall-bladder,  that  they  frequently 
occur  without  obstruction,  and  that  if  a  lodgment  of  the  stone 
actually  occurs,  this  almost  always  is  the  consequence  of  inflam- 
mation. Riedel  holds  this  inflammation  in  the  majority  of  cases 
to  be  non-infectious  and  designates  it  as  a  foreign-body  inflam- 
mation (Perialienitis  serosa),  whilst  others  and  I  also  are  of  the 
opinion  that  it  indeed  always  has  to  deal  with  an  infection  which 
has  invaded  the  gall-bladder  from  the  intestine  through  the  com- 
mon and  cystic  ducts.  The  result  of  this  inflammation  is  the 
softening  of  the  mucous  membrane  of  the  gall-bladder  and  the 
cystic  duct  and  a  transudation  of  serous  or  purulent  fluid  into 
the  hollow  organ.  The  gall-bladder  is  distended,  the  nerve 
endings  running  in  its  walls  are  dragged  upon,  and  so  arises  the 
picture  well  known  to  you  all  as  gallstone  colic.  The  more 
active  the  inflammation  breaks  out,  the  quicker  the  organ  dis- 
tends, so  much  greater  the  pain.  That  this  solely  is  excited  by 
the  distension  of  the  walls  of  the  gall-bladder  one  can  demon- 
strate in  this  wise  :  let  one  in  a  patient  on  whom  the  gall-bladder 
has  been  opened  and  a  fistula  established  inject  with  a  syringe 
into  the  gall-bladder  physiological  salt  solution  ;  immediately 
the  patient  complains  of  severe  cramp  of  the  stomach. 

Upon  the  degree  of  infection,  upon  the  number  and  virulence 
of  the  inwandering  micro-organisms,  of  the  bacterium  coli,  strepto- 
and  staphylococci,  depends  the  kind,  duration  and  intensity  of 
the  inflammation,  which  appears  as  serous,  sero-purulent,  pure 
purulent  and  gangrenous  cholecystitis.  It  often  resembles  a 
straw  fire,  which  only  a  moment  bursts  forth  and  quickly  burns 
out,  ere  that  the  patient  notices  anything  of  such  an  inflamma- 
tion. But  frequently  it  spreads  like  a  conflagration  in  the  neigh- 
borhood of  its  original  site,  seizes  upon  the  peritoneum,  the  liver, 
the  pancreas,  and  does  not  spare  even  widely  distant  points  : 
the  heart  and  the  lungs,  the  brain   and  the   kidneys.      Riedel  is 


PATHOLOGY  OF  CUOLETJTHIASIS.  29 

\o(  the  opinion  that  the  majority  of  obstructive  swellings  of  the 
cystic  duct  develop  slowly,  gradually,  and  without  symptoms, 
and  that  an  acute  cholecystitis  is  very  rare  in  a  gall-bladder  up 
till  then  healthy  ;  according  to  him  hydrops  first  occurs,  and 
then  acute  inflammation  of  the  dropsical  gall-bladder.  I  cannot, 
on  the  ground  of  my  observations,  completely  confirm  Riedel. 
Of  course  a  dropsical  gall-bladder  is  more  easily  exposed  to 
inflammation  than  one  with  a  patent  cystic  duct,  but  I  have  a 
series  of  proofs  that  very  frequently  an  acute  inflammatory  pro- 
cess can  set  in  also  in  a  gall-bladder  up  till  then  healthy  and 
with  a  patent  cystic  duct.  But  it  is  a  matter  of  indifference 
whether  the  cholecystitis  arises  more  frequently  in  a  dropsical  or 
in  a  healthy  gall-bladder ;  whether  the  inflammatory  process 
attracts  the  attention  of  the  gallstone  bearer  or  not,  in  this  we 
agree  :  the  gallstone  colic  depends  almost  always  upon  an  inflam- 
mation of  the  gall-bladder.  At  my  operations  I  have  seen  about 
all  stages  of  this  inflammation,  from  the  Hght,  scarcely  notice- 
able, quickly  passing  serous  form,  to  the  severest  form  of  chole- 
cystitis, developing  under  the  most  violent  local  and  general 
symptoms.  If  one  glances  over  the  changing  and  manifold  pic- 
ture of  cholecystitis,  one  may  thus  come  in  fact  to  the  belief  that 
the  different  forms  of  the  disease  must  be  ascribed  also  to  dif- 
ferent causes.  On  this  account  Riedel  has  held  that  it  is  neces- 
sary to  introduce  his  foreign  body  inflammation,  whilst  I  am  of 
the  opinion  that  one  more  naturally  can  explain  the  //>/?/  forms 
by  a  /ig-/it  infection  and  the  severe  ones  by  a  more  virulent  infec- 
tion. We  ought  surely  not  to  forget  that  the  varying  power  of 
resistance  of  the  organism  plays  a  role.  Corresponding  to  the 
degree  of  inflammation  I  found  the  contents  of  the  gall-bladder 
almost  normal,  mixed  with  only  a  few  shreds  of  mucus,  often  the 
bile  muddy  and  thickened,  many  times  also  pure  pus,  rarely 
ichorous  and  stinking.  Bacteria  were  often  absent  from  the  con- 
tents of  the  gall-bladder.  But  one  cannot  wonder  at  that,  if  we 
reflect  that  the  capacity  for  life  and  resistance  of  the  bacterium 
coli  is  very  sHght.      When   it  has  excited  the  infection,  it  dies 


30 


GALLSTONE  DISEASE. 


quickly  after  performing  its  work  and  is  no  longer  demonstrable. 
So  often  as  I  have  caused  the  bile  to  be  examined  for  bacteria, 
were  they  found  in  large  quantity  in  it,  so  that  I  personally  hold 
fast  to  the  origin  of  cholecystitis  from  infection.  Naunyn  also  is 
of  the  same  opinion,  as  may  be  seen  from  the  following  passages 
taken  from  his  Diisseldorf  paper.     There  he  says  : 

'*  The  cholecystitis  and  cholangitis  calculosa  are  from  begin- 
ning on  infections.  Whilst  normal  bile  is  sterile,  they  have  in  the 
fresh  cases  of  cholecystitis  calculosa  almost  always  bacterium  coli 
in  the  gall-bladder.  In  old  cases  the  bile  may  again  be  found 
sterile  ;  the  bacterium  coli  appears  in  short  time  to  die  and  dis- 
appear. 

**This  cholecystitis  and  cholangitis  coli-bacteria  seldom  becomes 
purulent,  except  the  peculiar  suppuration  exciters — staphylo-  and 
streptococci  are  added  ;  it  must  accordingly  be  distinguished 
from  real  empyema  of  the  gall-bladder  and  from  purulent  cholan- 
gitis ;  yet  they  also  can,  without  becoming  purulent,  cause  severe 
local  and  general  infection,  as  clinical  cases  and  experiments 
both  show.  The  experiments  show  also  why  the  bacterium  coli 
appears  so  quickly  in  cholecystitis  ;  so  long  as  the  flow  of  bile  is 
normal,  it  does  not  gain  access  to  the  bile  ducts,  but  this  hap- 
pens very  easily,  so  soon  as  the  flow  of  bile  is  checked." 

Let  us  turn  now  to  the  representation  of  the  changes  induced 
by  inflammation  of  the  gall-bladder.  The  different  degrees  of 
inflammation  show  themselves  most  clearly  in  the  condition  of 
the  mucous  membrane  of  the  gall-bladder.  It  is  either  slightly 
swelled  or  markedly  thickened,  strewn  with  decubital  ulcers, 
covered  with  diphtheritic  membrane  or  totally  necrotic.  That 
the  ulcer  formation  can  give  origin  to  strictures,  perforations, 
fistulae,  haemorrhages,  is  a  matter  of  course.  Especially  the 
ulcerous  processes  in  the  neck  of  the  gall-bladder  and  in  the 
cystic  duct  can  lead  to  persistent  destruction  and  obliteration  of 
the  duct,  so  that  the  gall-bladder  is  completely  excluded  from 
the  bile  system.  The  gall-bladder  then  becomes  a  cyst  with 
serous  or  purulent  contents.     The  inflammatory  process,  which 


PATHOT.OCxY  OF  CHOI.ELITHIASIS.  3 1 

passes  through  different  stages  in  the  gall-bladder,  frequently 
extends  to  the  wall  of  the  organ,  and  causes  marked  thickening 
and  oedema  of  the  serous  and  muscular  layers,  local  peritonitis, 
purulent  pericholecystitis  and  to  the  formation  of  adhesions  be- 
tween the  gall-bladder  on  the  one  side  and  omentum,  stomach 
and  intestine  on  the  other.  For  the  development  of  that  sort 
of  changes  in  the  surroundings  of  the  gall-bladder  it  is  in  no- 
wise necessary  that  the  gall-bladder  should  be  perforated  ;  peri- 
tonitic  processes  in  acute  sero-purulent  cholecystitis  are  also 
without  perforations  of  that  kind  of  daily  occurrence. 

I  wish  especially  now  to  emphasize  the  fact  that  the  serous 
inflammations  of  the  gall-bladder  can  be  cured  spontaneously 
unless  that  the  changes  in  the  walls  of  the  gall-bladder  and  its 
surroundings  have  already  advanced  too  far.  But  the  severer 
forms,  the  empyema  of  the  gall-bladder,  the  phlegmonous  and 
diphtheritic  inflammations,  leave  behind  always  more  or  less  in- 
jurious sequelae  and  ineffaceable  traces.  That  the  stones  which 
lie  in  the  gall-bladder  or  in  its  neck  remain  behind  after  the  sub- 
sidence of  the  infection  is  a  fact  to  the  meaning  of  which  we  will 
later  direct  your  attention.  The  slight  infection  in  the  gall- 
bladder subsides  for  the  most  part  very  quickly,  the  swelling  of 
the  mucous  membrane  of  the  cystic  duct  diminishes  and  nor- 
mal circulatory  relations  are  re-estabhshed.  The  transudation 
retained  in  the  gall-bladder  discharges  itself  through  the  cystic 
and  common  ducts  into  the  intestine.  Riedel  is  indeed  of  the 
opinion  that  such  an  occurrence  must  flood  the  liver  with  micro- 
organisms and  lead  to  diffuse  cholangitis.  I  am  in  this  connec- 
tion of  the  very  opposite  opinion,  and  believe  rather  that  a 
healthy  liver  by  its  vigorous  stream  of  bile  very  quickly  elimi- 
nates the  dangerous  fluid.  In  the  considerable  number  of  pa- 
tients I  have  seen,  the  gall-bladder  tumors  of  acute  cholecystitis 
so  quickly  disappear  within  a  few  hours,  that  one  could  not 
think  in  these  cases  of  a  resorption  of  the  gall-bladder  con- 
tents with  a  further  persisting  obstruction  of  the  cystic  duct. 
However,  I  will  of  course   not  assert  that  such  a  resorption   can 


32  GALLSTONE  DISEASE. 

by  no  means  occur.  For  how  can  one  otherwise  explain  the 
origin  of  a  hydrops  of  the  gall-bladder?  Surely  this  latter 
can  be  the  end  product  of  a  serous  cholecy.stitis  and  arise,  if  the 
infection  is  extinguished,  but  the  cystic  duct  further  remains  ob- 
structed, especially  by  a  stone.  Then  the  mucous  membrane  of 
the  gall-bladder  affords  a  water-clear  secretion  which  collects  in 
large  quantity  in  the  hollow-organ.  It  is  very  easy  to  suppose 
that  such  a  dropsy  of  the  gall-bladder  can  develop  as  a  conse- 
quence of  an  infection,  without  that  the  patient  is  at  all  conscious 
of  it,  since,  as  we  have  already  been  able  to  explain  above,  that 
it  is  not  at  all  necessaiy  that  a  slight  quickly  passing  infection 
should  come  to  the  knowledge  of  the  patient.  The  appendix 
vermiformis  can  also  become  dropsical  through  infection,  without 
that  its  bearer  is  at  all  aware  of  it. 

I  think  also  t/iat  iJic  appearance  of  sterile  zvater-clear  dropsy 
of  the  gall-bladder  is  explained  most  naturally  by  the  assumption 
of  a  quickly  passing  infection  of  slight  degree.  That  sometimes, 
in  exceptional  cases,  a  concretion  may  by  chance  so  lie  in  front 
of  the  cystic  duct  that  the  bile  in  the  gall-bladder  is  dammed 
back  I  will  by  no  means  contradict.  If  the  strength  of  the  bile- 
stream  in  the  gall-bladder  is  very  little,  indeed  almost  zero,  then 
the  possibility  of  the  origin  of  a  hydrops  through  purely  mechani- 
cal causes,  that  is  by  obstruction  from  a  stone,  is  not  to  be  abso- 
lutely denied. 

The  dropsy  of  the  gall-bladder  is  then,  to  express  my  views  in 
a  few  words,  most  frequently  the  end  product  of  an  acute  infectious 
cholecystitis  of  slight  degree.  Exceptionally  it  arises  by  a  stone 
having  obstructed  the  neck  of  the  gall-bladder  or  the  cystic  duct 
without  inflammatory  processes  participating  therein. 

Moreover  it  is,  if  we  have  in  mind  the  diagnosis  and  treatment 
of  chronic  dropsy  in  view,  quite  indifferent  how  we  explain  its 
origin,  and  I  think  that  a  discussion  of  such  debatable  questions 
is  little  suited  to  increase  the  interest  of  practising  physicians  in 
the  surgical  treatment  of  gallstone  disease.  For  the  possibihty 
of  a  complete  cure  of  a  cholecystitis  a  complete  restoration  of 


PATHOLOGY  OF  CHOLELITHIASIS. 


33 


the  lumen  of  the  duct  is  in  the  first  place  necessary.  By  abnor- 
mal i^crforations  into  the  stomach,  intestine  or  outward,  a  natural 
cure  is  imaginable ;  that  it  is  frequently  incomplete  I  might 
prove  to  you  by  different  examples.  I  remember  several  cases 
in  which  stones  of  more  than  walnut  size  had  been  passed  by 
the  anus  and  which  later  came  to  operation,  since  all  the  stones 
had  not  passed,  but  had  repeatedly  excited  severe  inflammations. 
At  any  rate,  such  perforations  of  the  gall-bladder  into  the  neigh- 
boring hollow  organs  belong  to  the  rarities  ;  much  more  frequent 
is  it  that  the  infectious  secretion  collected  in  the  gall-bladder 
empties  itself  into  the  intestine  through  the  cystic  and  common 
ducts  after  the  diminution  of  the  swelling  of  the  mucous  mem- 
brane of  the  cystic  duct.  Small  stones  may  in  this  way  be 
washed  farther  on,  but  ihucIl  more  frequently  will  the  stone  lodged 
in  the  cystic  duct  or  imbedded  in  the  neck  of  the  gall-bladder  re- 
main behind  in  its  accustomed  place.  The  cholecystitis  has  in 
vain  existed,  if  it  has  not  succeeded  in  driving  out  the  larger 
stones.     The  knowledge  of  this  fact  is  of  great  importance. 

Since  the  bile,  after  the  cystic  duct  has  again  become  free,  can 
anew  stream  in  and  out  of  the  bladder,  the  gall-bladder  again 
returns  to  its  former  repose,  and  the  gallstone  disease  returns  to 
a  condition  of  latency,  unless  it  is  prevented  therein  by  adhesions 
which  have  been  left,  the  meaning  of  which  we  will  return  to 
later,  and  by  extensive  changes  in  the  walls  of  the  gall-bladder. 
How  frequently  it  occurs,  that  the  cystic  duct  remains  perma- 
nently closed,  but  the  infection  of  the  gall-bladder  is  extinguished 
and  resorption  takes  place — a  process  which  we  may  designate 
as  apparent  cure  of  the  cholecystitis — and  how  frequently  hap- 
pens an  actual  cure  of  the  cystitis  with  restoration  of  the  lumen 
of  the  cystic  duct,  this  w^e  can  hardly  succeed  in  proving.  I 
have  in  accordance  with  my  experiences  the  conviction  that  the 
latter  method  will  be  most  frequently  observed. 

The  gall-bladder  after  the  subsidence  of  a  cholecystitis  can  be 
found  in  the  following  different  conditions  : 

I.   With   a   cystic   duct    closed   by  a   stone,   swelling   of  the 


34  GALLSTONE  DISEASE. 

mucous  membrane,  or  by  cicatrix  (thus  arises  hydrops,  if  the  infec- 
tion is  extinguished,  empyema  if  it  still  exists). 

2.  With  wide  open,  patent  cystic  duct,  completely  normal, 
with  but  slightly  altered  walls  or  adherent  to  the  neighboring 
stomach,  intestine  or  omentum,  and  united  by  fistulas.  The  stones 
themselves  may  be  evacuated,  but  will  in  most  cases  remain 
behind. 

How  the  common  duct  bears  itself  in  this  condition  will  later 
be  considered. 

The  inflammatory  process,  which  takes  places  in  the  gall- 
bladder, is  now  to  be  regarded  as  the  pushing  force  which  sets 
the  stone  in  motion.  Therefore,  it  is  of  great  importance  how 
large  the  stone  is  and  where  it  precisely  lay  when  the  inflam- 
mation commenced.  Thus  small  stones  resting  in  the  neck  of 
the  gall-bladder,  or  immediately  upon  the  cystic  duct,  may  be 
hurried  along  by  the  inflammation  into  the  common  duct. 
Having  reached  it,  they  make  a  pause  which  can  last  an  indefi- 
nitely long  time.  Yet  it  will  usually  not  last  long,  since  the 
stone  is  kept  in  a  certain  movement  by  the  bile  streaming  out  of 
the  hepatic  duct.  Moreover,  the  inflammatory  secretion  exuding 
from  the  gall-bladder  takes  care  that  quiet  does  not  long 
continue  in  the  common  duct.  But  if  it  is  discharged  with  the 
stone,  and  if  the  stone  is  not  so  large  that  the  bile  is  dammed 
behind  it,  then,  as  I  have  been  able  frequently  enough  to  con- 
vince myself,  will  the  stone  be  retained  just  as  quietly  as  in  the 
gall-bladder ;  not  only  weeks,  but  months  and  years  long.  It 
can  imperceptibly  grow  and  increase,  without  the  patient  has  a 
foreboding  of  the  dangerous  guest  which  he  harbors.  Suddenly 
it  discloses  itself  by  the  occurrence  of  colic,  jaundice  or  fever. 
Then,  as  in  the  case  of  a  stone  in  the  gall-bladder,  it  is  a  question 
of  an  inflammation  or  of  a  mechanical  obstruction  of  the  narrower 
parts  of  the  common  duct  lying  nearer  the  intestine.  The  stone 
in  the  common  duct,  if  it  is  not  over  large,  will  be  able  with 
violent  pains  to  pass  the  papilla  of  the  duodenum,  after  which 
the  patient  may  obtain  and  retain  relief,  unless  that  other  stones 


PATHOLOGY  OF  CHOLELITHIASIS.  35 

pursue  the  same  course.  If  the  stone  in  the  common  duct  is,  on 
account  of  its  size,  ill-suited  for  the  passage  of  the  peipilla,  then 
it  either  remains  sticking  in  the  common  duct  or  it  breaks 
through  into  the  free  peritoneal  cavity,  or  after  the  formation  of 
a  choledocho-duodcnal  fistula  into  the  intestine.  I  have  never 
observed  a  retrograde  wandering  of  a  stone  into  the  gall-bladder. 
Before  we  follow  further  the  fate  and  retention  of  the  stone  we 
must  intercalate  some  remarks  on  cholecystitis  and  its  results. 
The  inflammation  in  the  gall-bladder  preserves,  in  spite  of  its 
undeniable  dangers  for  the  patient,  one  great  advantage.  It  may 
lead  to  the  complete  cure  of  the  cholelithiasis.  I  understand  by 
cure  I,  the  expulsion  of  all  stones;  2,  the  complete  restoration 
of  the  patency  of  the  bile  duct;  3,  the  absence  of  inflammation 
or  its  consequences  (adhesions).  If  it  concerns  a  small  stone, 
suitable  to  pass,  or  if  all  the  concretions  are  expelled  by  a 
quickly  passing  inflammation,  which  leaves  no  adhesions  behind, 
then  is  a  restoration  ad  integrum  reached  with  which  the  patient 
can  be  very  content.  But  for  the  most  part  the  question  is  one 
concerning  many  stones.  One  or  a  few  are  expelled,  the  major- 
ity, especially  the  large  ones,  remain  sticking  in  the  gall-bladder 
or  in  the  cystic  duct ;  nevertheless,  as  we  have  seen  above,  all 
symptoms  can  decline,  the  cholecystitis  remains  longer  in  exist- 
ence, it  becomes  as  a  hydrops  of  the  gall-bladder  latent,  to  break 
out  later  when  opportunity  offers.  If  the  patency  of  the  cystic 
duct  is  again  restored,  so  that  the  bile  can  flow  in  and  out,  then 
the  cholelithiasis,  although  still  enough  large  stones  remain, 
enters  upon  a  period  of  latency  and  can  in  this  quiescence  repose 
until  death  puts  the  man  to  sleep  in  the  eternal  rest  of  the  grave. 
But  where  the  inflammation  has  once  found  a  favorable  soil, 
there  it  creates  a  locus  minoris  resistantiae,  which  it  always 
attacks  by  preference.  In  this  wise  is  the  fact  explained  that  the 
cholecystitis  appears  as  a  recurrent  disease,  which  in  its  relapses 
is  much  more  obstinate  than  appendicitis.  It  is  not  by  any 
means  common  that  gallstones  cause  a  single  attack  of  colic  ; 
they  do  not  let  their  hosts  off  so  easily,  but  torture  him  year  in 


36  GALLSTONE  DISEASE. 

and  year  out  without  let  up  or  end.  By  this  we  do  not  mean 
that  the  cohcs  must  present  their  former  violence  ;  on  the  con- 
trary, it  often  lets  up  and  in  its  stead  appears  an  obstinate  back- 
ache, or  a  nagging,  boring,  persisting  oppression  in  the  stomach. 
Scarcely  another  disease  runs  its  course  so  variably  as  chole- 
lithiasis and  changes  its  character  so  suddenly  as  it.  Yesterday 
the  most  violent  colic  raged  like  a  thunder-storm  ;  to-day  there 
has  come  a  calm,  which  leads  the  patient  to  quickly  forget  the 
horrible  condition  of  the  preceding  day.  Scarcely  has  the  vomit- 
ing disappeared,  when  the  appetite  quickly  returns,  the  sunken 
blanched  features  become  rosy  and  renew  their  youth,  and  no 
one  dreams  that  the  disease  is  making  further  progress.  And 
yet  in  spite  of  this  external  improvement  the  bile  in  the  gall- 
bladder turns  into  pus,  the  patient  has  no  suspicion  what  an  ex- 
plosive he  conceals  in  his  abdomen.  In  fact,  very  frequently  the 
disease,  with  perverse  hypocrisy,  conceals  under  a  beautiful  mask 
its  horrible  features,  and  unless  we  surgeons  now  and  then  upon 
a  time  had  the  courage,  with  skillful  hand,  to  tear  off  the  mask, 
we  never  would  have  obtained  a  conception  of  the  knaveries  and 
wiles  of  cholelithiasis.  It  passes  still,  especially  among  the  laity, 
as  a  harmless  disease,  which  is  not  worth  the  cost  of  an  opera- 
tion. How  often  has  this  optimistic  view  of  the  nature  of  chole- 
lithiasis caused  severe  and  irreparable  injuries,  and  how  fre- 
quently a  flourishing  life  has  been  blighted  which  might  have 
been  saved  by  an  early  operation  ! 

However,  with  the  best  intention,  I  have  wandered  from  my 
subject.  My  duty  is  to  treat  not  of  the  progress  of  cholecystitis, 
but  of  its  pathological  anatomy.  Yet  his  mouth  runs  over  whose 
heart  is  full,  and  I  think  that  my  involuntary  excursion  has  done 
no  injury  to  gallstone  patients. 

Returning  now  to  the  pathological  anatomy,  we  must  first 
direct  our  attention  to  the  inflammatory  processes  which  take 
l)lacc  in  the  neighborhood  of  the  gall-bladder,  and  which  we 
include  under  the  designation  pericholecystitis.  An  inflamma- 
tion has  as  a  consequence  that  the  gland  which  lies  upon  the 


PATHOLOGY  OF  CHOLELITHIASIS. 


37 


cystic  duct  swells  exactly  as  the  cubital  and  axillary  glands  can 
swell  if  the  man  has  gotten  a  panaritium  or  a  phlegmon.  The 
lymphadenitis  recedes  with  the  disappearance  of  the  cholecys- 
titis, with  frequent  relapses,  the  gland  remains  enlarged,  and  be- 
comes so  hard  that  it  can  simulate  a  stone.  More  numerous  than 
on  the  cystic  duct  are  the  glands  on  the  common  duct,  which  in 
inflammatory  processes  can  also  undergo  great  changes.  More 
important  than  the  changes  and  disease  of  the  glands  is  the  de- 
velopment of  adhesive  peritonitis  to  the  gall-bladder.  We  saw 
above  that  it  may  come  to  a  circumscribed  peritonitis  with  or 
without  a  perforation  of  the  gall-bladder,  as  a  consequence  of 
which  we  must  give  heed  to  the  numerous  adhesions  which  take 
place  between  the  gall-bladder  on  the  one  side  and  the  omentum, 
stomach  and  intestine  on  the  other.  Even  then,  when  all  stones 
are  expelled  from  the  gall-bladder  and  the  cystic  duct  has  again 
become  patent,  can  such  adhesions  give  rise  to  evil  troubles. 
The  pylorus  of  the  stomach  is  brouglit  into  sympathy,  the 
duodenum  is  kinked,  the  gallstone  patients  have  severe  stomach 
disorders.  They  acquire  a  hypertrophy  of  the  pylorus  and  dila- 
tation of  the  stomach.  By  the  implication  of  the  omentum  and 
the  colon  in  the  inflammatory  processes  the  dangers  of  ileus  are 
added.  Through  the  continuous  dragging,  which  the  adhesions 
occasion,  the  form  of  the  gall-bladder  will  be  changed  by  the 
traction  ;  it  can  take  on  diverticulum-like  dilatations  and  the  form 
of  an  hour-glass.  We  operate  frequently  on  account  of  such 
adhesions.  The  physician  who  does  not  know  how  to  estimate 
them  puts  on  a  puzzled  face  when  he  finds  no  stones — quite 
wrongly,  for  in  truth  the  adhesive  peritonitis  to  the  gall-bladder 
can  torture  the  patient  to  death.  The  regular  discharge  of  bile 
into  the  common  duct  is  hindered,  it  is  dammed  back  in  the  hol- 
low organ,  since  the  cystic  duct  is  kinked  and  excites  by  the 
excessive  tension  of  the  gall-bladder's  walls  the  most  violent 
colicky  pains.  I  will  now  indeed  remark,  that  it  is  best  to  extir- 
pate the  gall-bladder  ;  then  the  stasis  in  the  gall-bladder  can  no 
longer  occur,  or  the  colics  occasioned  by  it. 


38  GALLSTONE  DISEASE. 

If  it  concerns  an  empyema  of  the  gall-bladder  or  an  abscess 
in  its  neighborhood,  then  one  observes  often  the  most  remarka- 
ble perforations  in  different  directions.  That  circumscribed  sup- 
purations in  the  belly  are  capable  of  complete  involution,  the 
suppurations  of  the  appendix  prove  sufficiently  ;  likewise  a  puru- 
lent pericholecystitis  can  be  cured ;  but  certainly  in  most  cases 
the  pus  will  seek  an  outlet ;  and  so  arise  fistulous  formations  be- 
tween the  gall-bladder  itself,  or  the  abscess  lying  near  it  on  the 
one  hand  and  the  stomach  and  intestine  on  the  other.  Most 
frequently  arises  an  adhesion  of  the  gall-bladder  to  the  anterior 
abdominal  wall  ;  the  pus  seeks  for  itself  at  the  thinnest  point  of 
the  abdominal  wall,  often  at  the  navel,  a  way  out  (external  gall- 
bladder fistula).  Perforations  even  under  Poupart's  ligament 
have  been  observed,  while  ruptures  into  the  pelvis  of  the  kidney, 
the  bladder,  vagina,  pleura  or  lungs  belong  to  the  rarer  occur- 
rences. The  fistulae  formations  are  to  be  regarded  as  endeavors 
of  nature  to  bring  about  a  cure  ;  many  times  they  succeed,  often 
they  remain  futile,  evm  lead  to  a  sad  end.  I  have  seen,  as 
already  remarked  above,  not  much  good  of  these  attempts  of 
nature  to  cure.  Usually  still  enough  stones  remained  behind  or 
it  came  to  a  complete  emptying  of  the  gall-bladder,  while  a 
larger  stone  in  the  common  duct  pursued  its  mischief  further. 
The  inflammatory  process  in  a  gall-bladder,  till  then  healthy, 
occasions  a  distension  of  it  so  that  usually  it  is  possible  to  pal- 
pate it  as  a  tumor ;  after  the  resolution  of  the  inflammation  the 
gall-bladder  contracts,  and  with  frequent  repetition  of  the  chole- 
cystitis shrivels  always  more  and  more.  Its  walls  in  this  way 
often  become  thickened  in  incredible  layers.  If  again  the  in- 
flammation bursts  out  in  an  already  shrunken  gall-bladder,  it 
does  not  then  longer  succeed  in  distending  the  organ  so  that  a 
tumor  can  be  felt.  We  will,  in  speaking  of  the  diagnosis,  have 
to  explain  the  conditions  under  which  in  acute  cholecystitis  the 
gall-bladder  tumor  can  be  felt.  We  will  here  already  allude  to 
the  fact  that  not  rarely  an  empyema  occurs  in  a  shrunken  gall- 
bladder without  that  the  examining  physician  succeeds  in  demon- 
strating even  the  slightest  tumor. 


PATHOLOGY  OF  CHOLELITHIASIS. 


39 


The  gall-bladder  lies  many  times  far  up  under  the  liver,  and 
only  through  the  sensitiveness  to  pressure  of  the  gall-bladder 
will  we  be  directed  to  the  fact  that  everything  in  the  gall-bladder 
is  not  in  order.  No  fever  betrays  the  pus  in  the  gall-bladder, 
since  through  the  thick  adhesions  resorption  is  impossible. 

These  cases  also  are  still  capable  of  cure,  or,  more  properly 
said,  of  transition  into  the  latent  stage,  since  the  organ  becomes 
continually  smaller,  and  at  last  nothing  remains  behind  save  a 
cherry-sized  appendix,  in  whose  cavity  a  few  stones  and  a  few 
drops  of  serum  are  retained.  In  these  inflammatory  processes, 
which  establish  themselves  in  contracted  gall-bladders,  a  perfo- 
ration into  the  free  abdominal  cavity  is  very  rare,  because  nature 
has  drawn  all  round  so  firm  a  wall  of  adhesions  that  the  pus  no- 
where finds  a  place  to  break  through.  By  all  these  different 
stages  of  cholecystitis,  indifferently,  whether  it  relates  to  a  till 
then  normal,  dropsical,  or  contracted  gall-bladder,  enlargement 
of  the  liver  and  janndiee  are  almost  alzvays  ivanting.  The  liver 
does  not  enlarge,  since  it  is  not  at  all  involved ;  the  chole- 
cystitis is  indeed  an  entirely  local  disease,  limited  to  the  gall- 
bladder. One  part  of  the  liver  is,  however,  frequently  altered  ; 
that  is  the  part  of  the  liver  lying  over  the  gall-bladder,  which 
can  in  acute  cholecystitis  be  drawn  out  into  a  tongue-like  lobe, 
the  so-called  process  of  Riedel.  I  will  speak  later  of  its  mean- 
ing. Just  as  rare  as  general  enlargement  of  the  liver  is  jaundice 
in  cholecystitis.  The  appearance  of  jaundice,  which  patients 
and  physician  await  with  suspense  and  often  greet  with  joy,  be- 
longs, according  to  my  experience  with  cholecystitis,  absolutely 
to  the  exceptions. 

Naturally  if  the  inflammatory  process  succeeds  in  driving  the 
stone  out  of  the  cystic  and  into  the  common  duct,  and  if  the 
same  process  repeats  itself  here  as  in  the  gall-bladder,  then 
jaundice  will  appear  as  a  sign  of  the  obstruction  of  the  common 
duct.  But  since  acute  obstruction  of  the  common  duct  in  com- 
parison with  the  inflammatory  processes  occurring  in  the  gall- 
bladder is  relatively  rare,  so  is  jaundice   in   gallstone  disease  in 


40  GALLSTONE  DISEASE. 

general  not  very  frequent.  I  am  not  in  position  to  make  exact 
statements  as  to  the  frequency  of  cholecystitis  without  the  ex- 
pulsion of  the  stone,  and  how  often  acute  obstruction  of  the 
common  duct  occurs  with  expulsion  of  the  stones  into  the  in- 
testine. That,  neither  the  surgeon  nor  the  internal  clinician  can, 
in  my  opinion,  decide.  Both  see  only  the  severer  forms  of  chole- 
lithiasis, the  manifestations  of  the  irregular  form  of  Nauiiyn. 
Only  the  general  practitioner,  who  sees  all  forms  of  chole- 
lithiasis, could  enlighten  us  regarding  this  point,  assuming  that 
he  was  master  of  the  special  diagnosis  of  cholelithiasis.  If,  for 
instance,  a  country  physician,  with  a  large  competitionless  prac- 
tice— to-day  unfortunately  a  rarity — should  test  all  his  gallstone 
colics  with  regard  to  whether  they  are  to  be  regarded  as  an  ex- 
pression of  an  acute  cholecystitis  or  as  an  acute  obstruction  of 
the  common  duct,  then  we  would  obtain  enlightenment  on  the 
mutual  relation  of  the  gall-bladder  to  the  choledochus  colics. 

At  present  we  know  almost  nothing  regarding  it,  and  we  can 
only  launch  into  assumptions.  And  yet  I  as  a  surgeon  am  in- 
clined to  think  that  cholecystitis  without  expulsion  of  the  stone, 
the  "  unsuccessful"  attack  of  Riedel,  is  extraordinarily  frequent, 
and  that  the  acute  obstruction  of  the  common  duct  occurs  by 
far  not  so  often  as  one  heretofore  assumed.  At  all  events,  the 
old  saying  '*To  gallstone  disease  belongs  jaundice"  has  no 
longer  any  value  ;  and  even  in  cholecystitis  we  meet  jaundice 
only  then  when  the  inflammatory  process  in  the  gall-bladder  has 
extended  to  the  mucous  membrane  of  the  cystic  and  common 
ducts.  The  softening  of  the  mucous  membrane  hinders  the 
excretion  of  bile,  so  that  the  appearance  of  jaundice  is  imagin- 
able, even  though  the  duct  is  not  obstructed  by  a  stone. 

We  name  this  form,  with  Riedel,  inflammatory  jaundice,  in 
contrast  to  the  true  lithogenous  jaundice,  which  is  occasioned  by 
the  obstruction  of  the  choledochus  by  a  stone.  I  refrain  from 
discussing  in  detail  that  \^ery  interesting,  but  nevertheless,  up  to 
the  present,  right  obscure  subject  of  jaundice,  but  still  I  would 
like  to  give  expression  to  my  conviction  that  in  connection  with 


PATHOLOGY  OF  CIIOLELTTHTASIS.  4 1 

the  lithogenous,  mechanical  or  obstructive  jaundice  the  aka- 
thektic  or  functional  jaundice  plays  a  remarkable  role.  I  have 
operated  upon  a  considerable  series  of  patients  with  obstruction 
of  the  common  duct,  in  whom,  after  the  removal  of  the  stone,  I 
carried  out  drainage  of  the  hepatic  duct  and  was  able  to  divert 
externally  all  the  bile  ;  had  it  been  then  only  a  question  of  me- 
chanical jaundice,  then  this  would  of  necessity  have  speedily 
disappeared.  But  it  increased^  despite  the  excretion  of  enormous 
anuniJits  of  bile  (iip  to  looo  gr.),  and  so  I  believe  that  very  fre- 
quently the  jaundice  is  to  be  ascribed  to  severe  functional  dis- 
turbance of  the  liver  cells  themselves.  Leichtenstern  condenses  in 
a  few  sentences  that  which  it  appears  necessary  to  know  concern- 
ing functional  jaundice,  when  he  says  :  "  The  difficulty  in  ex- 
plaining the  origin  of  jaundice  with  notoriously  patent  gall  ducts 
has  been  in  recent  times  markedly  diminished  by  the  hypothesis, 
first  emitted  by  Minkowsky,  that  one  could  explain  the  origin  of 
a  jaundice  also  by  a  functional  disturbance  of  the  liver  cells, 
whose  function  might  be  to  excrete  certain  stuffs  ;  for  instance, 
sugar  into  the  blood  vessels,  bile  into  the  bile  duct,  and  other 
products  into  the  lymph  vessels.  A  disturbance  of  the  liver 
cells,  says  Minkowsky,  may,  without  a  mechanical  obstruction 
to  the  flow  of  bile,  occasion  a  passing  of  the  bile  constituents 
over  into  the  blood  or  lymph  vessels."  Independently  of  Min- 
kowsky, Liebermeister  has  recently  taught  a  very  similar  theor)% 
since  he  assumes  for  the  majority  of  the  forms  classified  as  hema- 
togenous icterus  a  disturbed  activity  of  the  liver  cells  ;  these 
latter,  in  consequence  of  injury,  lose  their  ability  to  excrete  the 
bile  in  the  direction  of  the  bile  ducts  ;  a  consequence  of  which  is 
the  diffiision  of  the  bile  into  the  blood  and  lymph  vessels  of  the 
liver.  This  jaundice  Liebermeister  calls  "  akathektic  "  or  "  diffu- 
sion icterus."  We  will  call  it  functional,  in  contrast  to  the  me- 
chanical jaundice.  E.  Pick,  one  of  the  principal  advocates  of  func- 
tional jaundice,  designates  the  prodrome  of  disturbed  liver  cell  ac- 
tivity, in  consequence  of  which  the  bile  passes  over  into  the  blood 
and  lymph  vessels,  b)^  the  name  paracholia,  and  distinguishes  : 
4 


42  GALLSTONE  DISEASE. 

(i.)  A  nervous  paracholia,  with  which  he  classes  the  icterus 
of  gallstone  colic  and  of  lead  colic  (reflex  from  the  sensitive 
nerves  of  the  gall-bladder  to  the  secretory  nerves  of  the  liver). 
Without  doubt,  here  belongs  emotional  jaundice,  of  the  occur- 
rence of  which  I  am  surely  convinced. 

(2.)  A  toxic  paracholia,  a  jaundice  occasioned  by  phosphorus, 
chloroform,  animal  poisons. 

(3.)  An  autointoxication-paracholia  occasioned  by  intestinal 
toxines.  Here  E.  Pick  would  have  classified  the  icterus  neona- 
torum. 

(4.)  Infection-paracholia.  Here  belongs,  according  to  this 
author,  the  falsely  so-called  **  catarrhal  "  jaundice,  which,  just  as 
''Weil's  disease"  and  "acute  yellow  atrophy,"  is  an  infection 
disease  sui  generis,  which  is  localized  in  the  intestine  from  which 
the  toxines  causing  the  jaundice  are  carried  to  the  liver." 

Indeed  these  different  theories  regarding  the  nature  of  jaundice 
prove  that  one  can  explain  the  origin  of  it  in  cholelithiasis  in 
very  different  ways.  At  any  rate,  the  appearance  of  jaundice  is 
a  sign  that  the  gallstone  disease  has  ceased  to  be  a  local  disease 
of  the  gall-bladder.  It  does  not,  however,  always  prove  true, — 
there  have  been  cases  of  jaundice  recognized,  in  which  only  the 
gall-bladder  was  diseased, — therefore,  the  practitioner  does  well 
with  every  jaundice  to  think  of  a  participation  of  the  liver  and 
common  duct  and  to  be  careful  in  formulating  the  prognosis.  If 
the  jaundice  has  lasted  only  a  few  days  and  is  it  of  slight  intensity 
then  is  one,  as  a  surgeon,  earnestly  inclined  to  imagine  a  transi- 
toiy  inflammatory  form,  or  one  hopes,  perhaps,  to  find  a  large 
stone  in  the  cystic  duct  which  impairs  the  patency  of  the  com- 
mon duct.  If  one  operates  then,  one  finds  frequently  an  acute 
obstruction  of  the  common  duct,  to  which  immediate  operation, 
as  we  shall  later  see,  is  little  suited.  Since  we  in  truth  possess 
no  means  of  clinically  differentiating  the  inflammatory  from  the 
lithogenous  icterus,  I  concede  that  the  physician  is  right  who  in 
gallstone  colic  with  acutely  appearing  jaundice  favors  more  an 
expectant  than  an  operative  course.      I  also  delay  in  such  cases 


i 


PATHOLOGY  OF  CHOLELTTIITASTS.  43 

with  operation,  until  I  believe  I  have  arrived  at  the  decision  that 
an  acute  obstruction  of  the  common  duct  does  not  exist.  Never- 
theless I  am  indeed  now  occupied  with  reflections  concerning 
the  indication  for  operation,  and  I  am  yet  still  very  far  from  the 
end  of  my  pathologico-anatomical  observations.  Here  it  is  still 
necessary  to  point  to  the  fact  that  by  the  passage  of  a  stone 
through  the  cy.stic  duct,  the  latter  can  experience  a  dilatation  so 
that  instead  of  a  twisted  and  serpentine  duct,  a  broad,  short  and 
direct  communication  exists  with  the  common  duct.  The  stone 
driven  into  the  cystic  duct  can  lie  there  for  years  ;  it  grows  and 
grows  from  the  size  of  a  pea  to  the  circumference  of  a  walnut. 
If  it  lets  the  bile  still  flow  by,  or  if  the  inflammation  in  the  gall- 
bladder is  extinguished,  then  the  patient  feels  nothing  of  its 
presence.  Further,  it  is  to  be  remembered  that  through  the 
inflammatory  process  a  stone  can  be  driven  into  the  common 
duct,  Vv^hich  there  remains  lying  and  grows,  whilst  a  second  stone 
through  a  new  inflammation  comes  into  the  cystic  duct  and 
establishes  itself  here  permanently,  whilst  the  secretion  retained 
in  the  gall-bladder  becomes  purulent.  There  arises  then,  in  con- 
nection with  the  obstruction  of  the  common  duct,  an  empyema 
of  the  gall-bladder.  I  would  not  find  words  enough  to  picture 
all  the  pathologico-anatomical  possibilities  for  which  we  must  be 
ready  in  our  operations.  For  instance,  pus  has  broken  out  of  the 
gall-bladder  into  the  abdominal  cavity ;  from  a  general  peri- 
tonitis, which  moreover  in  cholelithiasis  does  not  belong  to  the 
rarities,  a  wall  of  adhesions  protects,  yet  in  these  we  find  stones 
imbedded  and  so  firmly  grown  fast  that  one  might  believe  they 
had  originated  here.  Or  the  cholelithiasis,  in  spite  of  long  exist- 
ence, has  come  to  a  complete  cure  ;  instead,  the  head  of  the 
pancreas,  in  which  a  pancreatitis  interstitialis  has  spread,  remains 
.stone  hard,  and  while  the  gallstone  disease  may  be  regarded  as 
set  aside,  the  disease  of  the  pancreas  excites  severe  and  life- 
threatening  disturbances. 

The  pathological  changes  which  stones  in  the  common  duct 
occasion  are  about  the  same  as  those  w^hich   are  produced  by 


44  GALLSTONE  DISEASE. 

concretions  in  the  gall-bladder.  We  have  here  also  almost 
always  to  deal  with  inflammatory  processes  which  put  the  stone 
in  motion.  The  wedging  of  a  stone  in  the  common  duct  is  to 
be  regarded  a  secondary  process,  as  a  consequence  of  the  inflam- 
mation ;  a  mechanical  obstruction  without  infection  solely  through 
the  stasis  of  the  bile  is  certainly  a  great  exception.  As  in  the 
eall-bladder,  so  also  in  the  common  duct,  occurs  swellincr  of  the 
mucous  membrane,  suppuration,  the  formation  of  the  decubital 
ulcers,  which  much  more  rarely  than  in  the  cystic  duct  lead  to 
obliteration  of  the  duct.  It  is  in  the  nature  of  the  case  that  the 
choledochus,  through  which  bile  is  constantly  pressed,  will  not 
so  easily  be  closed  by  cicatrices  as  the  cysticus,  which,  lying  one 
side  of  the  bile  stream,  is  on  account  of  its  narrowness  far  more 
subject  to  obliteration.  Usually  the  common  duct  dilates  even 
to  the  size  of  the  finger.  Seldom  is  it  dilated  like  the  intestine  ; 
its  wall  becomes  thickened  ;  and  here,  just  as  in  the  gall-bladder, 
can  arise  perforations  and  adhesions  between  the  duct  and  stomach 
or  intestine,  through  which  fistulae  can  take  place  which  permit 
a  cure  by  nature.  A  stone  in  the  papilla,  especially  by  pressure, 
causes  a  choledocho-duodenal  fistula.  In  many  cases  the  in- 
flammation of  the  common  duct  spreads  to  the  surroundings  of 
the  duct  and  can  give  occasion  to  thrombophlebitis  of  the  branches 
of  the  vena  portarum,  and  the  stone  in  the  common  duct  is  on 
this  account  more  dangerous  than  one  in  the  gall-bladder  and 
cystic  duct,  since  the  former  disturbs  the  circulation  of  the  liver, 
and  easily  gives  rise  to  diffuse  purulent  cholangitis  and  liver 
abscess.  Whoever,  indeed,  believes  that  a  stone  in  the  common 
duct  must  necessarily  always  occasion  jaundice,  errs  very  greatly : 
even  a  large  stone  can  stick  in  the  common  duct  and  the  bile 
flow  by  it  without  hindrance  into  the  intestine.  Jaundice  does 
not  appear.  But  if  an  inflammation  drives  the  concretion  towards 
the  intestine  into  the  continually  narrowing  portions  of  the  chole- 
dochus, then  jaundice  does  not  let  us  long  await  its  appearance, 
to  again  quickly  disappear,  if  the  inflammation  lets  up  and  the 
stone  again  becomes  free  ;  that  is,  if  it  falls  into  the  intestine 
or  moves  back  into  the  dilated  choledochus. 


PATHOLOGY  OF  CHOLELITHIASIS.  45 

For  the  proper  appreciation  of  the  peithologico-anatomical 
chanii:es  in  obstruction  of  the  choledochus  it  is  essential  to  know 
exactly  the  state  of  the  gallstones  in  the  gall-bladder  and  in  the 
cystic  duct  and  the  condition  of  the  gall-bladder  walls.  Usually 
the  gall-bladder  is  small  and  shrunken  since  it  has  expelled  its 
stones  into  the  common  duct,  and,  by  the  numerous  inflamma- 
tions which  have  infested  it,  has  lost  its  distensibility.  Adhe- 
sions between  gall-bladder  and  intestines  are  almost  never  want- 
ing. The  cystic  duct  can  be  patent,  obliterated,  or  closed  by  a 
stone;  the  gall-bladder  not  rarely  communicates  with  a  hollow 
organ  of  the  abdomen  through  a  fistula.  It  is  of  great  impor- 
tance if  the  cystic  duct  remains  patent  and  the  bile  can  flow 
from  the  gall-bladder  directly  into  the  intestine.  The  symptom 
so  important  for  the  diagnosis  of  chronic  occlusion  of  the  com- 
mon duct,  jaundice,  can  then  be  entirely  wanting.  Only  excep- 
tionally is  the  gall-bladder  distended  in  chronic  occlusion  of 
the  common  duct  by  stone  ;  especially  then,  if  it  is  complicated 
with  a  hydrops  or  an  empyema  of  the  gall-bladder,  and  the  oc- 
clusion of  the  common  duct  has  occurred  relatively  early.  In 
obstruction  of  the  common  duct  by  tumors  (carcinoma  of  the 
head  of  the  pancreas)  it  is  the  rule  that  the  gall-bladder  is  large 
and  dilated.  It  may  be,  however,  that  one  has  to  do  with  a 
patient  whose  gall-bladder  in  consequence  of  cholelithiasis  is 
contracted,  and  the  head  of  w^hose  pancreas  was  later  at- 
tacked by  carcinoma.  Just  as  seldom  as,  with  stones  in  the 
gall-bladder  and  cystic  duct,  the  liver  enlarges,  just  so  frequently 
do  we  find  enlargement  of  the  liver  in  case  of  stone  in  the  com- 
mon duct.  After  persistent  closure  of  the  duct,  cirrhosis  of  the 
liver  can  set  in  with  all  its  consequences.  Every  physician 
knows  that  in  connection  with  purulent  processes  in  the  gall- 
bladder and  gall  ducts  pycemic  and  septic  conditions  can  de- 
velop ;  and  in  fact  liver  abscesses,  acute  haemorrhagic  nephritis, 
endocarditis,  meningitis,  abscesses  of  the  lung  are  by  no  means 
rare  complications  of  cholelithiasis.  Even  more  dangerous  than 
these    consequences    is    carcinoma    of    the    gall-bladder.     Two 


46  GALLSTONE  DISEASE. 

principal  forms  of  this  latter  are  to  be  distinguished,  according 
to  Morin,  as  well  in  pathologico-anatomical  as  in  clinical  rela- 
tions. The  cancer  arising  from  the  epithelium  of  the  gall-blad- 
der spreads  rapidly  to  the  liver,  and  is  in  the  beginning 
accompanied  neither  by  jaundice  nor  by  ascites.  One  cannot 
distinguish  it  symptomatically  from  primary  cancer  of  the  liver. 
The  cancer  arising  from  the  glands  of  the  gall-bladder's  mucous 
membrane  remains  longer  limited  locally  to  the  gall-bladder, 
and  leads  in  time  to  a  compression  of  the  bile  ducts  and  to 
jaundice. 

It  is  an  uncontrovertible  fact  that  the  concretions  furnish  the 
stimulus  to  cancer  formation.  Courvoisier  found  in  87.5  per 
cent.,  Delano  Ames  in  95.4  per  cent,  of  the  cases  of  gall-blad- 
der cancer  at  the  same  time  gallstones.  According  to  Schroeder, 
14  per  cent,  of  gallstone  sufferers  sicken  with  cancer.  Rela- 
tively frequent  have  I  found  severe  inflammatory  processes  in 
cancerously  degenerated  gall-bladders.  Carcinomata  are  rare 
in  the  common  duct  and  do  not  develop  so  regularly  in  connec- 
tion with  cholelithiasis  as  cancer  of  the  gall-bladder.  I  will  not 
leave  the  pathological  anatomy  of  gallstone  disease  without  yet 
once  again  emphasizing  the  fact  that  inflammation  plays  the 
leading  role  in  all  the  symptoms  of  cholelithiasis,  by  which  this 
many-sided  disease  makes  itself  known.  The  fact  that  anger  or 
an  error  in  diet  can  excite  an  attack  of  colic  is  not  to  be  ignored, 
and  I  have  been  thoroughly  convinced  that  one  cannot  explain 
all  forms  of  colic  by  the  idea  of  an  inflammation.  For  instance, 
patients  with  a  general  enteroptosis,  especially  with  prolapse  of 
the  liver,  may  have  pains  which  one  can  well  explain  by  an 
atony  of  the  gall-bladder.  Large  and  lax,  with  thin  walls,  the 
organ  lies  here  in  the  belly,  without  a  stone,  an  inflammation 
or  an  adhesion  is  to  be  found.  The  muscular  structure  of  the 
gall-bladder  is  so  weakened  that  it  cannot  expel  the  bile  col- 
lecting in  the  gall-bladder.  The  bile  is  dammed  back,  distends 
the  walls  of  the  gall-bladder,  and  thus  excites  colicky  pains. 
How  far  the  muscular  powers  of  the  bile  ducts,  the  pressure  of 


PATHOLOGY  OF  CHOLELITHIASIS.  47 

the  diaphragm  and  the  abdominal  pressure  participate  in  the 
expulsion  of  stones  is  in  nowise  as  yet  determined.  For  small 
stones  a  powerful  contraction  of  the  gall-bladder  may  suffice  to 
expel  the  stones.  At  all  events,  the  practitioner  does  best  if  in 
the  majority  of  colics  he  thinks  of  an  inflammatory  process  and 
directs  his  treatment  against  it. 

Even  Naunyn  does  not  contradict  the  view  of  the  surgeons  that 
almost  every  colic  begins  with  a  cholecystitis.  At  all  events,  he 
cannot,  as  he  says,  find  another  similarly  lucid  cause  for  the  ex- 
planation of  gallstone  colics.  I  have  recently,  on  the  assump- 
tion that  I  had  to  deal  with  inflammatory  jaundice,  operated  a 
couple  of  times  in  acute  obstruction  of  the  common  duct,  and 
although  I  am  conscious  of  having  transgressed,  in  this,  the  ope- 
rative indications,  yet  such  procedures  contribute  to  the  solution 
of  the  question  how  far  inflammatory  processes  play  a  role  in  the 
origin  of  colic.  I  can  only  say  that  I  always  found  inflammatory 
processes  (oedema  of  the  gall-bladder  walls,  adhesions  just  form- 
ing, serous  and  purulent  exudate  in  the  gall-bladder  and  bile 
ducts),  and  the  presence  of  the  bacterium  coli  could  always  be 
proven.  For  me  there  is  not  the  slightest  doubt  that  it  is  the 
infection  which  changes  the  cholelithiasis  from  a  latent  into  an 
active  condition.  Whoever  does  not  believe  this,  him  I  invite  to 
be  present  at  my  operations  ;  he  will  then  quickly  come  around 
to  my  way  of  thinking.  I  have  only  pictured  the  pathological 
anatomy  of  cholelithiasis  in  coarse  lines  in  order  to  lay  the  neces- 
sary foundation  for  the  discussion  of  its  separate  forms.  There- 
fore, it  cannot  be  my  duty  to  exhaustively  discuss  all  the  sequehe 
which  develop  in  connection  with  cholelithiasis,  such  as  abscess 
of  the  liver,  perforation,  peritonitis,  etc.  If  I  wished  to  describe 
all  the  remarkable  changes  which  I  have  met  in  my  numerous 
operations,  then  I  would  have  to  put  your  patience  to  a  severe 
proof.  Only  I  must  emphasize  one  thing  before  I  pass  to  the 
diagnosis  :  almost  every  case  of  cholelithiasis  brings  surprises  of 
remarkable  sort ;  no  one  is  like  another,  and  each  requires  a  very 
special  study  of  its  pathologico-anatomical  changes.      If  one  may 


48  GALLSTONE  DISEASE. 

nuikc  a  trivial  comparison,  which  you  will  kindly  pardon  me,  j 
thus  can  one  say  :  As  rarely  as  one  nose  in  the  human  features  ! 
is  like  another,  just  so  rarely  does  one  operative  condition  resem- 
ble another.  Thus  I  have  for  example  in  my  last  two  operations 
found  conditions  such  as  I  have  never  before  seen  in  my  more 
than  400  operations.  In  one  case  I  came  upon  an  hour-glass 
formed  gall-bladder,  one-half  of  which  contained  pus  and  the 
other  clear  bile,  whilst  the  passage  was  strictured.  In  the  other 
I  stumbled  upon  a  complete  obliteration  of  the  choledochus  at 
the  mouth  of  the  cystic  duct,  caused  by  a  stone  which  here, 
through  an  ulcer,  had  led  to  a  complete  impermeable  stricture 
of  the  common  duct.  The  duodenal  part  of  the  common  duct 
was  converted  into  a  pus-containing  cyst,  and  it  was  wonderful 
that  one  found  no  bile  in  the  hepatic  duct  above  the  stricture,  a 
fact,  the  explanation  of  which  is  only  possible  on  the  assump- 
tion of  a  very  high  degree  of  functional  disturbance  of  the 
liver  cells,  due  to  the  month-long  existing  stasis.  I  brought 
the  case  to  cure  by  a  resection  of  the  stricture  from  the  con- 
tinuity of  the  common  duct  and  by  subsequent  drainage  of  the 
hepatic  duct. 

These  two  examples  may  suffice  to  lay  before  you  the  mani- 
fold character  of  the  processes  among  which  cholelithiasis  pro- 
gresses. I  can  assure  you  that  it  frequently  is  very  difficult  for 
me  to  find  my  way  in  the  chaos  of  adhesions  to  survey  the  deep- 
lying  ducts  and  rightly  interpret  the  operative  condition.  If  in 
my  last  100  operations,  as  frequently  enough  happened,  I 
stumbled  upon  changes  such  as  I  never  till  then  had  observed, 
I  could  not  refrain  from  expressing  my  joy  that  in  the  beginning 
of  my  surgical  activity  in  the  field  of  gallstones  I  had  been  spared 
strange  cases  of  that  sort.  x\t  that  time  it  would  have  been 
simply  impossible  for  me  to  get  my  landmarks  and  to  carry  out 
a  proper  treatment.  At  all  events  must  every  surgeon  who  does 
gallstone  operations  concur  when  I  assert  :  TJic  pathological 
anatomy  of  cholelithiasis  forms  the  foundation  for  its  special  diag- 
nosis and  treatment,  and  without  its  exact  understanding  we  can 


PATHOLOGY  OF  CHOLELITHIASIS.  49 

neither  frame  good  diagnoses  nor  initiate  a  rational  treatment. 
For  th^  proof  of  this  assertion  I  will  not  long  remain  in  your 
debt ;  the  next  lectures  will  adduce  it,  and  I  would  be  thankful 
to  you  if  then  you  should  follow  my  deductions  with  similar 
attention  to  that  of  to-day. 


4 


LECTURE  II. 

THE    AMNESIS   AND    EXAMINATION    IN    CHOLE- 
LITHIASIS. 

Gentlemen  :  If  wc  are  called  by  a  gallstone  patient  to  his  as- 
sistance, because  he  is  tortured  with  severe  colic,  then  we  will 
not  immediately  take  out  the  hypodermatic  syringe,  but  first 
convince  ourselves  that  the  pains  which  rage  in  the  abdomen 
of  the  patient  are  really  gallstone  colics.  In  this  the  amnesis 
gives  us  in  many  cases  great  assistance.  I  lay  great  importance 
upon  the  proper  estimate  of  the  patient's  previous  history,  and 
often  is  the  examination,  with  all  its  particulars,  not  so  valuable  as 
an  exact  inquiry  into  the  disease  processes  which  the  patient  has 
up  till  then  observed  in  himself.  How  often  have  I,  solely  from 
the  letter  of  a  colleague,  who  sent  me  his  patient  for  operation, 
made  the  correct  diagnosis  !  So  last  year  a  patient  was  sent  to 
me  from  Carlsbad  who  suffered  from  marked  attacks  of  fever, 
which  appeared  in  the  manner  of  malaria.  Jaundice  and  colic 
seemed  in  this  case,  in  fact,  to  play  a  subordinate  role,  and  yet 
after  the  very  explicit  letter  of  my  Carlsbad  colleague  I  could 
not  an  instant  doubt  but  that  we  would  find  a  chronic  occlusion 
of  the  choledochus  by  a  stone.  When  the  patient  came,  she 
was  so  content  and  in  such  good  spirits  that  she  most  gladly 
would  have  gone  away  ;  and  what  I  could  establish  by  the  ex- 
amination was  of  so  slight  a  nature  that  one  could  not  have 
formed  from  the  results  of  the  examination  an  indication  for 
operation.  The  liver  was  only  moderately  enlarged,  jaundice 
and  pains  on  pressure  were  wanting,  and  the  fever  also  had  dis- 
appeared on  entrance  into  the  clinic  ;  but  the  interrogation,  con- 
ducted with  the  greatest  care,  made  me  certain  that  a  large  stone 

50 


AMNESIS  AND  EXAMINATION  IN  CHOLELITHIASIS.  5  I 

must  be  lodged  in  the  common  duct.  The  operation,  undertaken 
solely  on  the  ground  of  the  amnesis,  brilliantly  confirmed  the 
diagnosis  which  had  been  made.  I  know  only  too  well  that  it  is 
not  always  possible  to  take  the  previous  history  of  the  disease  with 
the  desired  exactness  ;  the  patient  has  long  forgotten  when  his 
disease  had  begun,  and  in  this  relation  will  especially  the  stomach 
cramps  be  regarded  as  not  belonging  to  the  picture  of  gallstone 
disease.  Most  patients  must  first  at  some  time  have  been  jaun- 
diced, before  they  permit  themselves  to  be  convinced  that  they 
suffer  from  gallstones.  Furthermore,  an  exact  enlightenment  con- 
cerning the  previous  history  is  shattered  by  this,  that  the  patient, 
tortured  by  the  most  violent  pains,  feels  little  inclination  to  an- 
swer the  many  cross-questionings  of  the  physician.  He  demands 
and  wishes  nothing  more  than  release  from  his  torture.  And  the 
physician  acts  tactfully  therein  if  he  takes  in  such  a  case  only  a 
short  history,  and  limits  the  examination  as  much  as  possible  so 
as  to  quickly  take  the  morphine  syringe  and  inject  the  welcome 
and  pain-assuaging  fluid.  But  good  I  cannot  indeed  call  it  if 
the  physician  merely  reaches  under  the  bedclothes,  and  without 
observing  the  abdomen  convinces  himself  by  a  momentary  grop- 
ing of  the  enormous  sensitiveness  of  the  epigastrium.  It  is 
indeed  for  the  moment,  in  most  cases,  a  matter  of  indifference 
whether  we  have  to  deal  with  an  attack  of  gallstone  colic  or 
with  a  stomach  cramp,  for  the  treatment  is  so  much  the  same  ; 
yet  it  is  still  of  great  consequence  that  one  should  immediately 
make  a  correct  diagnosis.  What  cannot  this  fearful  pain  in  the 
region  of  the  stomach  mean  !  It  can  be  an  innocent  gastralgia, 
or  the  approaching  perforation  of  an  ulcer  of  the  stomach,  a 
serous  cholecystitis,  or  a  severe  form  of  purulent  inflammation 
which,  indeed,  after  a  few  days,  can  lead  to  death.  So  much 
time  must  even  the  busiest  practitioner  have  that  he  at  least 
makes  the  attempt  to  investigate  thoroughly  the  cause  of  the 
pain  ;  for  we  should  not  forget  that  the  weal  or  woe  of  gallstone 
patients  depends  only  upon  early  diagnosis.  It  is  a  grievous 
wrong  for  the  physician  to  seek  to  calm  the  patient  and  his  rela- 


52  GALLSTONE  DISEx-YSE. 

tiv^cs  by  throwing  out  lightly  the  remark,  "  It  is  only  a  cramp 
of  the  stomach!"  If  he  takes  a  few  minutes'  time,  wdth  few^ 
questions  concerning  the  previous  course  of  the  disease,  to  in- 
vestigate well  the  kind  of  pain,  then  will  it,  indeed,  become  by 
that  means  clear  that  it  is  a  case  of  gallstone  colic.  The  fol- 
lowing points  in  the  taking  of  the  amnesis  now  deserve  our 
attention  : 

1.  The  Age  and  Sex, — Gallstones  are  very  rare  in  the  first 
twenty  years,  and  then  increase  in  frequency.  In  higher  age 
they  wall  for  the  most  part  be  observed.  That  the  female  is 
more  disposed  to  cholelithiasis  than  the  male  sex  is  a  fact  from 
the  nearer  investigation  of  which  I  refrain. 

2.  The  Diseases  of  Parents  and  Brothers  and  Sisters. — 
In  many  families  cholelithiasis  is  very  much  at  home.  Often  the 
patient  relates  that  his  mother  has  suffered  from  gallstones,  his 
father  died  of  cancer  of  the  gall-bladder,  and  of  his  brothers 
and  sisters,  two  suffer  with  their  stomach.  With  the  enormous 
frequency  of  gallstones  I  do  not  lay  the  great  weight  w^hich 
Riedel  does  upon  the  heredity  of  cholelithiasis,  but  where  I 
diagnosticate  gallstones  in  people  whose  parents  have  died  from 
cancer  of  the  most  different  organs,  then  I  hold  it  for  my  duty 
to  warn  them  of  the  fact  that  14  per  cent,  of  all  gallstone  cases 
sicken  of  cancer  of  the  gall-bladder,  and  that  the  operation  is 
more  indicated  w'ith  patients  so  threatened  than  W'ith  others. 
Yes,  even  there,  wdiere  I  find  a  gall-bladder  filled  with  stones 
which  occasion  absolutely  no  discomfort,  I  am  accustomed  to 
recommend  the  operation,  if  the  amnesis  discloses  that  the  par- 
ents of  the  stone-bearer  have  died  from  cancer. 

3.  The  Previous  Diseases  of  the  Patient  Herself. — The 
children's  diseases  play  no  role  here.  With  sure  proofs  of  lues 
and  articular  rheumatism,  w^e  wall  ponder  the  necessity  of  an 
operation.  Frequently  we  may  determine  that  after  typhoid,  or 
a  gastro-duodenal  catarrh  with  jaundice,  the  first  symptoms  of 
cholelithiasis  appeared.  In  many  amneses  we  hear  of  appen- 
dicular inflammations,  of  right-sided  movable  kidney,  of  ulcers 


AMNESIS  AND  EXAMINATION  IN  CIIOLEEITITIASIS.  53 

of  the  stomach,  and  frequently  enough  I  have  been  able  by  my 
operations  to  establish  that  of  the  three  diseases  not  a  trace  was 
to  be  found.  The  right  kidney  was  immovably  firm,  and  was 
also  not  dislocated  a  single  centimeter  ;  the  appendix  was  free 
from  adhesions  and  nowhere  kinked  ;  in  the  stomach  one  could 
prove  no  trace  of  ulcers.  That  the  demonstration  of  a  healed 
ulcer  is  difficult  for  even  a  surgeon,  who  opens  widely  the  abdo- 
men and  carefully  palpates  the  stomach,  is  a  fact  to  which  we 
will  later  return. 

4.  The  Kind  of  Pain. — Its  character,  its  localization,  its  ap- 
pearance, its  dependence  upon  meals,  must  be  carefully  exam- 
ined by  us  in  order  to  find  the  diagnostic  points  which  differentiate 
the  pain  of  ulcer  from  gallstone  colic.  Its  differentiation  is  so 
important  that  I  will  later  devote  an  especial  chapter  to  it.  Here 
may  we  only  hint  that  gallstone  colic  pains  are  frequently  de- 
pendent upon  the  beginning  of  menstruation  or  of  pregnancy, 
and  to  the  gynaecologist  it  has  long  been  known  that  in  connec- 
tion with  operations  which  he  performs  upon  the  uterus  and  its 
appendages  not  very  rarely  attacks  of  gallstone  colic  occur. 
Sudden  changes  in  the  relations  of  the  circulation  of  the  abdo- 
men appear  to  play  a  large  role  in  the  transition  of  cholelithiasis 
from  the  quiescent  to  the  active  stage.  The  same  is  true  of 
trauma.  Of  course,  external  injuries  produce  no  formation  of 
gallstones,  but  concretions  resting  quietly  can,  by  the  inflamma- 
tion which  trauma  sets  up,  be  set  in  motion.  The  physician 
ought  to  know  this,  since  he  may  come  into  a  position  where  he 
will  have  to  explain  this  to  accident  insurance  or  artisans'  benefit 
associations.  I  will  report  upon  several  cases  in  which  there 
can  be  no  doubt  that  the  occurrence  of  gallstone  colic  had  been 
excited  by  external  influences. 

5.  The  Occurrence  of  Jaundice. — Although  jaundice  occurs 
in  gallstone  disease  relatively  seldom,  at  least  by  far  not  so  fre- 
quently as  one  was  wont  to  assume  heretofore,  yet  it  forms  in 
the  amnesis  an  important  factor.  ''  Have  you  ever  had  jaun- 
dice ?  "     This  question  we  must  always  ask,  and  we  learn   then 


54  CxALLSTONE  DISEASE. 

whether  it  appeared  immediateh^  with  the  first  cramp  attack,  or 
first  later,  how  long  it  continued,  what  intensity  it  assumed, 
whether  it  remained  the  same  or  changed.  Especially  in  chronic 
obstruction  of  the  common  duct  by  a  stone  is  it  extremely  im- 
portant to  determine  the  intensity  of  the  jaundice,  and  we  are 
then,  solely  on  the  ground  of  the  circumstances  of  the  jaundice, 
often  enough  in  position  to  differentiate  chronic  choledochus 
obstruction  by  stone  from  tumor.  Yet  ma}'  we  now  be  per- 
mitted to  point  out  that  in  lithogenous  choledochus  obstruction 
the  jaundice  ordinarily  changes,  whilst  in  obstruction  by  tumor 
it  constantly  increases  in  intensity.  At  this  opportunit}'  we 
inquire  immediately  after  the  condition  of  the  stools,  whether 
they  change  their  color  or  remain  uniformly  free  from  color. 

6.  Appearance  of  Fever.— This  is  obsei*ved  in  all  possible 
symptoms  of  cholelithiasis,  but  it  is  especially  characteristic  in 
the  lithogenous  choledochus  obstruction  b}'  reason  of  its  inter- 
mittent form.  We  inquire  after  the  height  of  the  fever,  its  dura- 
tion, and  are  frequently  in  position  to  determine  the  inflamma- 
tory progress  which  the  gallstones  have  excited  by  attention  to 
the  relations  of  the  fever. 

7.  Relations  of  the  Stomach. — Just  so  frequently  as  the 
stomach  is  disturbed  in  its  function  during  the  colics,  just  so 
often  can  it  in  the  interval  be  perfectly  healthy.  The  patient 
may  digest  the  most  exceptional  tidbits,  but  usually  he  suffers 
from  eructations,  distension  and  nausea.  If  vomiting  is  present, 
we  inform  ourselves  how  the  \-omitus  looked — whether,  for  ex- 
ample, it  was  mixed  with  blood  ;  whether  at  any  time  a  stone 
has  been  vomited  ;  we  scarcely  need  to  ask  after  this,  since  the 
patient  of  his  own  accord  relates  such  an  occurrence.  The  cir- 
cumstance that  cholelithiasis  is  not  rarely  complicated  with  car- 
cinoma and  ulcus  ventriculi  brings  with  it  the  necessity  of  our 
devoting  our  particular  attention  to  the  condition  of  the  stomach 
in  taking  our  amnesis. 

8.  Condition  of  the  Intestine. — Man}'  gallstone  patients 
years  long  pass  for  patients  having  intestinal  troubles,  and  they 


[ 


AMNESIS  AND  EXAMINATION  IN  CHOLELITHIASIS.  55 

themselves  believe  themselves  to  be  so,  since  with  regular  bowels 
the  colics  occur  more  rarely.  One  hears  often  repeated,  "  If  the 
wind  passes  freely,  then  I  always  feel  well,"  and  many  have  set 
aside  their  gallstone  colics  by  using  injections.  The  occurrence 
of  stones  in  the  feces  is  the  best  criterion  of  the  presence  of 
cholelithiasis.  The  return  of  colored  feces  after  long-continued 
icterus  is  hailed  with  joy  by  doctor  and  patient.  Unfortunately, 
this  joy  frequently  does  not  last  long,  for  the  gray  color  of  the 
stools  returns  again,  since  the  stone,  which  lodged  in  the  com- 
mon duct,  had  only  changed  its  place  for  a  short  time  and  had 
not  passed.  The  complaint  that  frequently  at  one  time  diarrhoea, 
at  another  constipation,  occurs,  is  heard  very  frequently  in  the 
amnesis,  and  it  seems  to  me  that  this  change  in  consistence  of  the 
feces  is  to  be  ascribed  to  adhesions  which  develop  between  the 
gall-bladder  and  intestine. 

9.  The  Condition  of  Body  Weight. — During  the  colic  one 
shows  no  inclination  to  take  food  or  drink  ;  he  loses  weight,  to 
quickly  recover  it,  if  the  gallstone  disease  remains  localized  in 
the  gall-bladder  and  the  inflammatory  processes  abate.  With 
freciuent  recurrences  the  organism  is  not  in  condition  to  take  on 
again  always  the  former  weight,  and  the  emaciation  makes  still 
greater  progress  if  the  stomach  is  involved  in  the  complication 
and  jaundice  appears.  In  its  chronic  form,  without  cancer  occur- 
ring, a  cachexia  may  develop  which  reminds  one  of  the  cancerous 
cachexia.  Many  patients  will  be  absolutely  unchanged  in  their 
general  condition  by  their  gallstone  suffering  ;  they  look  sun- 
browned  and  weather-seasoned,  and  many  a  corpulent  woman 
with  a  respectable  layer  of  fat  in  her  abdominal  walls  does  not 
look  as  if  she  almost  weekly  suffered  from  colic,  with  violent 
vomiting. 

10.  Occurrence  of  Nervous  Symptoms. — We  cannot  be 
surprised  that  the  gallstone  patient,  through  constant  pains,  so 
suffers  in  his  nerves  that  the  slightest  excitement  drives  the  bile 
into  his  blood  ;  it  is  sufficiently  known  that  anger  for  men  who 
suffer  with  their  liver  and  from  gallstones  is  the  greatest  poison. 


56  GALLSTONE  DISEASE. 

Very  frequently  I  have  observed  that  gallstone  patients  suffer 
from  migraine,  and  that  this  disappears  when  the  stones  are 
removed  by  operation.  Patients  with  chronic  jaundice  react  with 
particular  sensitiveness  to  psychical  impressions. 

II.  The  Use  of  Morphine. — It  goes  without  saying  that  the 
physician  from  humane  considerations  seeks  to  assuage  the 
pains  of  gallstone  colic  by  a  powerful  dose  of  morphine,  but  un- 
fortunately the  amnesis  very  frequently  discloses  that  the  patient 
himself  takes  the  syringe  in  hand  and  at  his  own  discretion 
makes  use  of  it.  It  is  very  important  that  the  physician  should 
inform  himself  exactly  how  frequently  the  patient  has  recourse 
to  morphine,  since  the  treatment  takes  its  indications  very  much 
from  it.  There  is  no  better  means  to  bring  the  deleterious  con- 
sequences of  morphine  to  a  halt  than  operation,  and  a  physician 
himself,  whom  I  ha\'e  delivered  from  gallstones,  was  of  the  opin- 
ion that  the  indications  for  operation  was  for  such  patients  to  be 
sharply  framed  who  could  at  all  times  put  themselves  in  posses- 
.sion  of  this  noble  and  yet  so  detestable  means.  Physicians, 
apothecaries,  sick  attendants,  if  they  have  violent  colics  and  gladly 
and  often  flee  to  the  hypodermatic  syringe,  ought  rather  to  take 
the  slight  risks  of  an  early  operation  than  to  accustom  them- 
selves to  a  drug  in  the  renunciation  of  which  only  a  few  succeed. 

We  can,  in  taking  the  amnesis,  obtain  valuable  landmarks, 
which  afford  us  enlightenment  as  to  how  far  the  disease  has  pro- 
gressed. Thus,  for  example,  the  patient  often  knows  how  to  spec- 
ify how  his  gall-bladder  has  behaved,  and  whether  it,  as  a  tumor, 
was  to  be  palpated  in  the  separate  attacks.  One  of  my  patients, 
who,  indeed,  is  himself  a  physician,  had  been  able  accurately  to 
follow  the  different  phases  of  his  disease.  He  had  been  able  in 
the  first  attacks  to  determine  the  size  of  the  inflammatory  gall- 
bladder tumor,  and  had  accurately  felt  how  the  inflammatory 
process  had  invaded  the  surroundings  of  the  gall-bladder  ;  how 
to  the  cholecystitis  a  pericholecystitis  associated  itself.  The 
layman  is  not  in  position  to  give  us  valuable  explanations  of  that 
sort,  )'et  we   learn   by  an   accurate   examination   many  a  thing 


AMNESIS  AND  EXAMINATION  IN  CHOLELITHIASIS.  57 

which  may,  without  an  examination,  lead  to  an  accurate  diag- 
nosis. At  all  events,  gentlemen,  I  can  only  give  you  the  advice, 
in  obtaining-  the  previous  history^  proeced  ivitJi  the  greatest  care. 
The  exannnatio}i,  tvhieh  follozvs  the  amnesis,  will  be  thereby 
greatly  siuiplified. 

It  is  self-evident  that  the  examination  should  have  re""ard  to 
not  only  the  field  of  dise^ise,  the  liver  and  gall-bladder,  but  the 
entire  body.  The  patient  should  so  far  divest  himself  of  clothing 
that  one  can  submit  every  organ  of  the  body  to  the  examination. 
If  we  are  called  to  the  patient's  house,  we  find  him  usually  in 
bed,  since  he  usually  is  having  a  colic ;  if  he  comes  in  the  inter- 
val in  the  consultation  hours  of  the  physician,  then  one  places 
him  upon  a  convenient  examination  sofa ;  to  undertake  the 
examination  on  a  sitting  or  standing  patient  leads  to  nothing. 
The  physician  places  himself  on  the  right  side  of  the  patient  and 
turns  his  face  to  him.  Good  light  should  be  provided,  since, 
indeed,  one  can  observe  many  an  important  thing  by  inspection. 

Before  we  begin  the  special  examination  of  the  diseased  organ 
we  convince  ourselves  of  the  condition  of  the  heart  and  luncrs  : 
and  the  surgeon  especially  has  reason  for  all  this,  since  from  the 
condition  of  these  organs  it  depends  whether  he  at  all  under- 
takes an  operation  or  what  anaesthetic  he  chooses.  We  do  not 
neglect  to  determine  the  quality  of  the  pulse  and  to  take  the 
bodily  temperature.  If  it  is  necessary  we  examine  by  rectum 
and  vagina,  and  convince  ourselves  of  the  motor  power  of  the 
stomach  by  trial  breakfast,  draw  out  the  stomach  contents,  and 
determine  the  chemistry  of  the  stomach's  digestion.  No  physi- 
cian would  neglect  to  examine  the  urine  for  albumin,  sugar  and 
bile  coloring-matters,  and  to  inspect  the  stools  and  determine 
their  color.  Bile  coloring-matters  are  always  found  where  jaun- 
dice exists  ;  albumin  is  met  with  in  the  diseases  of  the  bile  ducts 
attended  with  fever,  usually  in  slight  amount  only  ;  sugar  ap- 
pears now  and  then.  I  cannot  confirm  the  frequent  finding  of 
sugar  in  the  urine  which  has  been  reported  from  Czerny's  clinic. 
The  regular  search  of  the  feces  for  stones,  as  important  as  it  is, 
5 


58  GALLSTONE  DISEx\SE. 

is  practically  not  always  possible  to  carry  out.  If  a  stone  passes 
out  of  the  choledochus  into  the  duodenum,  or  if  it  break  through 
a  fistula,  it  strolls  about,  many  times  a  right  long  time,  in  the 
intestine  before  it  sees  the  light  of  day.  We  must  also  often  for 
weeks  continuously  search  the  stools  of  the  patient,  and  since 
we  cannot  always  trust  in  the  conscientiousness  of  others,  we 
would  be  obliged  ourselves  to  conduct  this  scarcely  appetizing 
business.  One  cannot  exact  of  the  physician,  who  has  many 
gallstone  cases  under  treatment,  that  armed  wuth  sieve  and  stick 
he  should  spend  his  time  in  stool  analyses  ;  and,  further,  we 
ought  not  to  forget  that  not  to  find  a  stone  is  no  proof  that  a 
stone  has  not  passed.  The  soft  masses  crumble  simply  in  the 
intestine  and  dissolve.  I  give  my  patients  always  the  following 
advice  :  "  Observe  carefully  the  color  of  the  stools.  So  long  as 
they  are  putty-colored  they  need  not  be  examined  more  closely ; 
so  soon  as  the  brown  color  returns,  then  is  it  necessary,  if  one 
wishes  to  run  down  the  stone."  If  one  finds  some,  then  it  natu- 
rally proves  that  the  colic  attack  has  been  successful ;  but  since 
experience  teaches  that  by  one  attack  all  stones  are  rarely  ex- 
pelled, so  is  the  further  observation  of  the  relations  of  the  gall- 
bladder and  liver  much  more  important  than  all  the  sifting  and 
stirring  of  feces.  They  credit  continually  the  hot  springs  of 
Carlsbad  with  easily  expelling  the  stones  from  the  gall-bladder 
into  the  intestine.  But  how  seldom  is  it  there  possible  to  con- 
trol the  result  of  the  stone-expelling  action  of  the  Sprudel.  If 
the  patient  there  has  drunk  the  Sprudel  in  the  early  morning, 
then  he  exercises  in  the  open  air,  and  drinks  his  coffee  and  his 
milk  in  one  of  the  coffee-houses  lying  at  a  distance  from  the 
town,  in  the  valley  of  Tepl.  How  frequently,  then,  must  he 
hasten,  if  the  action  of  the  springs  sets  in,  sooner  than  he  ex- 
pected. With  a  rational  cure  in  Carlsbad  it  is  clearly  impossible 
to  control  the  expulsion  of  stones. 

The  general  examination  of  gallstone  patients  is  under  no 
circumstances  to  be  neglected  ;  but  frequently  the  man  will  forget 
concerning   his   disease,  and  solely  from  his   general  condition 


AMNESIS  AND  EXAMINATION  IN  CHOLELITHIASIS.  59 

(obesity,  diabetes,  gout,  etc.)  will  it  depend  whether  we  treat 
him  medically  or  surgically. 

The  special  examination  begins  with  the  inspection.  Already 
at  the  first  glance  will  an  experienced  diagnostican,  for  instance, 
from  the  existence  of  jaundice,  the  expression  of  the  face,  from 
the  presence  of  cachexia,  be  able  to  make  his  diagnosis.  Thus 
one  can,  in  fact,  frequently  decide  by  inspection  whether  chronic 
obstruction  of  the  common  duct  from  a  stone  or  a  tumor  exists. 
I  had  for  six  years  an  attendant,  who,  like  every  attendant,  eagerly 
making  diagnoses  on  his  own  account,  often  announced  to  me, 
with  weighty  expression  and  proud  mien,  '*  Doctor,  there  is  in  the 
waiting-room  a  patient  with  jaundice,  but  he  has  no  stone,  only 
cancer!"  The  attendant,  who  in  six  years,  as  he  said,  had  ^ls- 
sisted  at  about  300  operations — naturally  he  had  no  other  duties 
than  to  keep  the  operating-room  clean — had  gradually  learned 
that  jaundice  is  rarely  so  intense  in  obstruction  of  the  common 
duct  by  stone  as  in  the  obstruction  by  carcinoma.  Almost 
always  had  this  fellow  made  the  correct  diagnosis.  Of  course 
a  carcinoma  patient  is  usually  a  greater  sufferer  than  a  man 
with  lithogenous  choledochus  obstruction ;  but  the  latter  also 
may  so  fail  that  he  looks  like  a  cancer  patient,  especially  then, 
if  fever  comes  on,  and  the  infection  advances  further.  The 
patient  produces  then  an  impression  of  extraordinary  suffering. 
We  should  not  rely  so  very  much,  however,  on  inspection,  since 
otherwise  we  would  leave  unoperated-upon  patients  with  decided 
cancerous  cachexia,  to  whom,  by  an  operation,  perfect  health 
could  again  be  given.  I  recall  several  cases  from  my  practice 
in  which  the  physicians  previously  treating  them  had  positively 
diagnosticated  a  cancerous  affection,  whilst  there  were  gallstones 
only. 

If  we  turn  our  attention  to  the  field  of  the  disease,  that  is  to 
say,  to  the  right  hypochondrium,  then  we  see  indeed  frequently, 
in  spare  patients,  the  lower  liver  border  stand  out  clearly.  If 
we  cause  the  patient  to  breathe  deeply,  then  the  liver  moves 
before   our   eyes,   following  the   respiratory  movements   of  the 


6o  GALLSTONE  DISEASE. 

diaphragm  up  and  down.  Often  the  hydrops  of  the  gall-bladder 
or  the  organ  distended  with  an  empyema  appears  as  a  globular 
tumor.  It  also  ascends  and  descends  with  the  respiration,  unless 
fixed  by  adhesions.  We  notice  in  acute  cholecystitis  the  char- 
acteristic prominence  of  the  right  hypochondrium  and  the  pit  of 
the  stomach,  which  points  to  the  inflammatory  processes  going 
on  there.  Is  the  gall-bladder  visible  as  a  tumor,  but  with  it 
there  is  marked  jaundice,  then  there  is  almost  always  a  tumor  on 
the  choledochus,  which  compresses  this  duct.  During  the  in- 
spection further  on  we  give  attention  to  the  relations  of  the 
stomach,  whose  pylorus  may  be  adherent  to  the  gall-bladder  by 
inflammatory  processes.  Even  without  filling  it  with  air,  it  will 
be  indeed  clear  to  us  from  inspection  that  it  is  dilated.  With 
attention  we  follow  the  peristalsis  of  the  bowels,  which  not  rarely 
ceases  in  the  region  of  the  gall-bladder  and  becomes  reverse 
peristalsis  ;  from  this  we  assume  adhesive  and  inflammatory 
processes  in  the  gall-bladder,  and  we  err  rarely  in  this  assumption. 
Of  all  methods  which  we  bring  into  use  in  gallstone  dis- 
ease, the  palpation  is  the  most  important.  It  is  extraordinarily 
difficult  to  learn  palpation  from  a  description.  Many  a  doctor, 
who  has  sufficient  practice  and  experience,  nevertheless  never 
learns  it,  since  lightness  of  hand  is  wanting  in  him.  Tlie  art  and 
manner  of  examination  is  at  all  events  frequently  not  properly 
pursued,  and  for  this  reason  I  allow  myself  some  remarks  in  re- 
gard to  this.  The  patient  assumes  the  back  position,  draws  his 
knees  up  and  opens  his  mouth,  whilst  he  breathes  quietly.  The 
head  ought  in  any  event  not  to  lie  too  high.  It  is  necessary  to 
examine  with  the  warmed  hand,  since  cold  excites  muscular  con- 
traction. It  is  thoroughly  wrong  if  one  rushes  immediately  to 
the  seat  of  disease  ;  much  more  does  it  appeal  to  mc  to  first  ex- 
amine the  parts  of  the  abdomen  which  are  apparently  free  from 
pain,  the  left  side  of  the  lower  abdomen,  and  then  first  gradually 
to  approach  the  seat  of  the  pain.  If  one  has  determined  that  the 
region  of  the  gall-bladder  is  sensitive,  then  one  inquires  of  the 
patient  regarding  the  kind  and  intensity  of  the  pain,  and  con- 


AMNESIS  AND  EXAMINATION  IN  CnOLELITIIIASIS.  6 1 

vinces  himself  that  the  middle  line  above  the  navel  and  the 
region  of  the  appendix  is  free  from  pain.  Now  one  determines 
how  extensive  the  pciinful  region  is,  during  which  one  gives  heed 
to  employ  an  uniformly  very  delicate  pressure.  In  so  doing  I 
am  always  readily  inclined  to  draw  comparisons  to  convince  the 
patient  that  the  sensitiveness  to  pressure  is  solely  localized  in 
the  region  of  the  gall-bladder.  At  all  events  the  physician 
should  penetrate  very  gently  into  the  deeper  parts  with  the  finger- 
tips, so  as  to  avoid  muscular  contractions.  The  fingers,  in  so 
doing,  are  held  outstretched,  and  one  does  well  to  divert  the  at- 
tention of  the  patient  from  the  examination  by  asking  some 
questions  concerning  the  previous  history  of  his  disease.  This 
manner  of  examination  suffices  only  for  the  fewest  cases,  as,  for 
instance,  when  it  concerns  large  tumors  of  the  gall-bladder,  or 
if  the  peritoneum  participates  in  the  inflammatory  process.  By 
the  bimanual  examination  we  attain  to  far  better  results.  Dur- 
ing this  the  patient  remains  quietly  lying,  as  formerly.  Involun- 
tarily will  he  advance  toward  the  physician  and  seek  to  lighten 
the  examination,  since  he  lays  himself  somewhat  toward  the  left 
side  and  raises  himxself,  by  which  the  back  and  abdominal  muscles 
are  put  in  contraction.  On  this  account  one  should  seek  to 
keep  the  patient  in  a  quiet  position.  The  doctor  lays  the  left 
palmar  surface  of  the  hand  on  the  right  side  of  the  patient's 
back,  and  presses  long,  carefully,  but  strongly,  the  liver  from 
behind  upward  against  the  curvature  of  the  ribs,  whilst  the  right 
hand,  lying  on  the  gall-bladder  region,  palpates  gently  and 
cautiously  the  diseased  parts.  Then  frequently  appears  that 
which  could  not  be  determined  by  the  simple  examination,  the 
egg-shaped  figure  of  the  gall-bladder,  or  one  feels  that  limited 
resistance  which  is  so  important  for  the  making  of  the  diagnosis. 
Only  in  case  of  excessive  tenderness  does  the  patient  so  con- 
tract his  abdominal  muscles  that  all  endeavors  by  palpation  to 
attain  our  end  are  in  vain.  Also  then,  if  the  gall-bladder  with 
its  fundus  does  not  reach  the  lower  border  of  the  liver,  but  lies 
concealed  high  up  under  the  liver,  will  it  elude  the  examining  fin- 


62  GALLSTONE  DISEASE. 

ger,  although  it  is  distended  with  inflammatory  or  purulent  ex- 
udation. These  are  the  cases  which  the  practising  physician  ought 
to  thoroughly  recognize,  since  a  suppurative  inflammation  can 
quite  well  exist  in  a  gall-bladder  inaccessible  to  palpation,  whilst 
jaundice,  enlargement  of  the  liver  and  fever  are  completely 
wanting.  Just  here  is  the  bimanual  procedure  often  decisive, 
since  one  with  frequent  use  of  the  same  can  always  again  prove 
a  painfulness  concentrated  at  a  particular  point.  The  palpa- 
tion of  the  gall-bladder  we  follow  with  that  of  the  Hver  ;  we  es- 
tablish its  enlargement  or  its  contraction,  its  consistence  ;  we 
palpate  the  lower  liver  border,  whether  it  is  sharp  or  rounded, 
and  glide  gently  with  the  finger  over  its  smooth  or  uneven  upper 
surface.  In  the  common  cholecystitis,  changes  in  the  liver  are 
scarcely  to  be  demonstrated  ;  very  much  more  frequently  have  I 
observed  that  the  gall-bladder  itself  and  the  inflammatory  pro- 
cesses which  have  taken  place  in  the  adhesions  in  the  neighbor- 
hood of  the  gall-bladder  have  been  regarded  as  enlargement  of 
the  liver.  One  part  of  the  liver  at  least  enlarges  frequently  in 
cholecystitis,  as  I  have  remarked  in  the  pathological  anatomy; 
that  is  the  part  of  the  liver  overlying  the  gall-bladder,  which 
grows  downward  into  a  tongue-like  process,  and  can  easily  give 
occasion  to  confusion  with  right-sided  movable  kidney.  Further 
on  I  will  give  the  necessary  information,  in  the  more  explicit 
description  of  conditions  of  gall-bladder  tumors,  how  one  may 
guard  himself  from  such  an  error.  With  cholangitis  and  chronic 
cholcdochus  obstruction,  the  liver  is  markedly  enlarged,  its  con- 
sistence considerably  changed.  In  chronic  obstruction  of  the 
common  duct  by  a  stone,  one  seeks  usually  in  vain  for  the  gall- 
bladder, whilst  in  obstruction  of  the  common  duct  by  a  tumor  it 
is  as  a  tumor  clearly  to  be  palpated.  To  this  very  important 
point  in  differential  diagnosis  I  have  already  pointed  when  dis- 
cussing inspection. 

If  we  can  palpate  a  liver,  it  is  by  no  means  declared  that  it  is 
enlarged  or  diseased.  Women  who  suffer  from  enteroptosis 
exhibit  livers  the  lower  borders  of  which  far  surpass  the  normal 


AMNESIS  AND  EXAMINATION  IN  CHOLELITHIASIS.  63 

boundaries.  By  lacing,  the  form  of  the  Hver  can  be  changed  in 
such  a  way  that  the  largest  part  of  the  right  lobe  may  extend 
far  down  deep  in  the  abdominal  cavity. 

We  need  percussion  to  prove  these  conditions. 

On  the  whole,  the  practitioners  of  internal  medicine  percuss 
better  than  the  surgeons,  whilst  the  surgeons,  on  the  other  hand, 
can  palpate  better  than  the  internists.  I  also  percuss,  but  I  can- 
not assert  that  I  have  obtained  actual  enlightenment  for  the 
separate  forms  of  cholelithiasis.  I  have  in  view  in  this  connec- 
tion, of  course,  only  the  tumor  of  the  gall-bladder.  In  disease 
of  the  liver  percussion  gives  us  many  a  valuable  enlightenment. 
We  determine  the  upper  and  lower  boundaries  of  the  liver  dull- 
ness, and  thus  obtain  a  picture  of  the  size  of  the  organ.  If  we 
percuss  the  gall-bladder,  we  then  must  understand  that  the  results 
of  this  sort  of  percussion  little  correspond  to  the  actual  con- 
dition which  the  later  operation  discloses.  One  should  assume 
that  the  region  over  the  palpable  gall-bladder  is  dull,  and  that 
the  dullness  of  the  gall-bladder  passes  directly  over  into  that  of 
the  liver.  Whoever  then  believes  that  this  is  always  so,  errs 
greatly  ;  yet  of  this  later. 

By  auscultation  also  we  attain  little  in  cholelithiasis.  The  rat- . 
tling  of  stones  can  only  occur  with  patent  cystic  duct,  never  in 
cholecystitis.  In  this  there  is  so  much  exudate  in  the  gall- 
bladder that  the  rubbing  of  the  stones  against  one  another  is 
absolutely  impossible.  Where  the  bile  can  flow  in  and  out,  gall- 
stone disease  represents  only  a  harmless  ill  ;  if  they  rattle  also, 
if  one  feels  the  stones  through  the  abdominal  walls,  then  is  oper- 
ation never  necessary  save  in  the  cases  which  I  have  indicated  in 
speaking  of  the  amnesis.  A  systolic  blowing  to  and  fro,  vas- 
cular murmur,  is  said  to  have  been  heard  in  the  bemnning  of  an 
attack.  Since,  as  a  surgeon,  I  very  rarely  see  a  case  in  its  first 
beginning,  I  can  permit  myself  no  judgment  concerning  this 
point.  I  have  never  succeeded  in  hearing  a  peritoneal  rub,  de- 
spite I  have  good  ears  and  have  to  deal  frequently  with  circum- 
scribed inflammations  of  peritoneum  on  the  gall-bladder  and  the 


64  GALLSTONE  DISEASE. 

neighboring  portions  oi^  the  Hver's  covering.  At  all  events,  I 
trust  most  to  palpation,  less  to  percussion,  and  least  of  all  to 
auscultation. 

One  method  of  examination  I  do  not  at  all  employ — that  is  a 
diagnostic  exploratory  puncture. 

Never  ought  a  doctor  to  make  the  attempt  by  an  exploratory 
puncture  to  learn  the  contents  of  a  palpable  tumor.  I/e  ivould 
be  guilty  of  a  technical  error.  Even  without  fever  existing, 
pus  may  lurk  in  the  gall-bladder,  and  then  the  contents  are 
under  so  high  a  pressure  that  after  the  withdrawal  of  the  finest 
needle  the  gall-bladder's  contents  may  discharge  into  the  ab- 
dominal cavity  and  cause  at  least  local,  if  not  diffuse,  peritonitis. 
What  does  the  practitioner  gain  by  a  tapping  ?  Indeed,  the  with- 
drawal of  a  syringeful  of  pus  is  the  best  encouragement  for 
operation.  But  if  the  physician  himself  cannot  operate — and 
gallstone  operations  should,  as  a  rule,  be  done  in  hospitals  or 
clinics — then  the  immediate  removal  into  a  hospital  may  not 
hinder  that  the  peritonitis  makes  further  progress,  and  the  oper- 
ator often  enough  is  no  longer  able  to  again  make  good  the 
injury  brought  about  by  the  tapping.  Even  the  surgeon  him- 
self, who  makes  an  exploratory  puncture  on  account  of  gall- 
bladder tumor,  finds  no  favor  in  my  eyes  even  then  if  he  follows 
it  by  an  immediate  operation.  Exploratory  pmicture,  mildly  ex- 
pressed, is  a  inisdenieanor  which,  under  all  circumstances,  must  be 
let  alone.     It  is  of  no  value,  and  it  in  many  cases  injures. 

It  has  happened  to  me  not  rarely  that  I  have  been  called  to 
gallstone  patients,  and  I  was  expected  to  decide  by  an  examina- 
tion under  an  anaesthetic  whether  an  operation  was  necessary  or 
not.  I  know  very  well  that  one  better  feels,  during  the  narcosis 
with  lax  abdominal  walls,  the  organs  concealed  in  the  depths  of 
the  abdomen  ;  but  I  cannot  say  a  word  in  behalf  of  narcosis 
solely  for  the  purposes  of  examination  in  cholelithiasis,  even  if 
then  one  immediately  follows  it  with  the  eventually  necessary 
operation.  The  necessity  for  the  operation  will  be  better  deter- 
mined by  the  clinical  progress   of  the   disease,   and  where  the 


AMNESTS  AND  EXAMINATION  IN  CHOLELITHIASIS.  65 

examiner  detects  no  tumor,  no  painfulness,  especially  notliint; 
abnormal  in  liver  and  gall-bladder,  one  is  seldom,  even  in  the 
narcosis,  in  the  position  to  find  any  sort  of  a  landmark  for  the 
necessity  of  an  operative  procedure.  "  Here  is  a  tumor  in  the 
abdomen  ;  we  will,  under  anaesthesia,  determine  from  what  organ 
it  arises."  With  this  invitation  am  I  frequently  enough  met.  I 
think  we  have  other  means  than  the  always  dangerous  chloro- 
form and  the  troublesome  ether  to  reveal  the  situation  of  a  tumor  ; 
attention  to  the  previous  course  of  the  disease,  exact  examina- 
tion, tests  of  the  motor  and  chemical  functions  of  the  stomach, 
of  the  stools,  etc.,  will  clear  up  the  results  of  palpation  and  fre- 
quently enough  help  to  a  correct  diagnosis.  Up  till  the  present, 
one  has  rarely  succeeded  with  the  Rontgen  rays  in  demonstra- 
ting gallstones,  and  the  magnificent  discovery  is  scarcely  suited 
to  further  extending  the  special  diagnosis  of  gallstones.  Very 
lately  they  have,  on  the  ground  of  the  condition  of  the  blood 
(difference  in  form,  size,  staining  of  the  red  corpuscles,  the  in- 
crease of  mononuclear  leukocytes,  etc.),  made  the  diagnosis  of 
carcinoma  of  the  bile  ducts  in  cases  in  which  symptoms  of  an 
empyema  of  the  gall-bladder  were  mo.st  prominent. 

On  this  account  I  would  very  much  recommend  a  thorough 
examination  of  the  blood  in  questionable  cases. 

The  results  of  the  present  explanation  concerning  amnesis 
and  examination  may  be  condensed  as  follows  :  That  an  exact 
study  of  the  previous  history  of  the  case  and  a  thorough  exami- 
nation give  us  extraordinarily  valuable  data  concerning  the  stage 
of  the  disease.  Before  a  field  marshal  sends  his  forces  into 
battle,  he  sends  out  his  scouts  to  clear  up  the  position  of  the 
eneni}'.  Upon  this  information  he  makes  his  disposition  de- 
pendent, and  often  enough  declines  to  attack,  if  he  be  convinced 
that  the  right  time  has  not  yet  come  for  battle.  He  defers  the 
attack  until  the  chances  are  better  for  winning  a  victory  and 
withdraws.  We  physicians  frequently  enough  stand  powerless 
when  opposed  to  disease  ;  a  thorough  amnesis  and  examination 
make  it  clear  to  us  that  the  hour  has  not  yet  struck  in  which 
6 


66  GALLSTONE  DISEASE. 

to  undertake  a  victorious  contest  with  the  disease.  The  surgeon 
has,  indeed,  every  reason  not  to  leave  unemployed  the  intelligence 
service  which  is  afforded  by  a  careful  attention  to  the  previous 
history  and  an  examination  carried  out  with  every  modern  assist- 
ance. The  general  does  not  let  his  artillery  immediately  gallop  to 
the  neighboring  heights,  from  there  to  hurl  its  death-carrying  shot 
upon  the  enemy.  He  does  not  immediately  and  without  defi- 
nite plans  hurl  his  cavalry  upon  his  opponent,  but  he  first  weighs 
and  then  tries.  When  we  physicians  carefully  observe,  exam- 
ine and  inform  ourselves  regarding  all  questions,  we  create  for 
ourselves  the  best  means  to  meet  victoriously  the  two  greatest 
enemies  of  mankind  and  of  the  physician — disease  and  death. 

Yet  there  is  need,  if  we  have  the  separate  forms  of  gallstone 
disease  in  mind,  of  still  very  numerous  reflections  and  consid- 
erations, which  will  be  discussed  in  our  next  lecture. 


LECTURE  III. 
THE  SPECIAL  DIAGNOSIS    OF  CHOLELITHIASIS. 

Gentlemen  :  In  to-day's  lecture  we  will  occup)'  ourselves 
with  the  special  diagnosis  of  cholelithiasis.  As  I  was  able  to 
say  in  the  pathological  anatomy  the  majority  of  gallstone  colics 
are,  in  my  opinion,  the  expression  of  an  inflammatory  process  in 
the  gall-bladder.  The  inflammation  causes  pain,  since  the 
secretion  collecting  in  the  hollow  organ  stretches  its  walls.  The 
pain  is  indisputably  the  most  prominent  symptom  of  gallstone 
disease,  for  the  patient  thinks,  indeed,  usually  a  disease  of  slight 
consequence,  if  it  occasions  him  no  pain,  and  the  physician  is  in 
the  great  majority  of  gallstone  cases  summoned  to  the  assist- 
ance of  the  patient  solely  on  account  of  the  pain.  A  large 
gall-bladder  filled  with  pus  causes  its  bearer  little  anxiety  if  no 
colics  are  present,  and  fever  and  jaundice  are  often  borne  a  long 
time  by  the  patient  without  his  deeming  it  necessary  to  call  in 
medical  help.  The  pain  always  remains  the  center,  about  which 
revolves  the  attention  of  the  doctor  and  the  patient.  For  this 
reason  I  regard  a  thorough  description  of  the  different  exhibi- 
tions or  expressions  of  pain  in  cholelithiasis  as  indicated. 

The  pain  of  gallstone  colic  is  of  very  different  nature.  It  is 
not  necessarily  always  cramp-like,  nor  does  it  show  itself  always 
with  extraordinary  violence.  There  are  not  always  "  pains  which 
even  to  swooning  overcome  a  Hercules,  and  prostrate  women 
who  have  stoically  borne  the  agonies  of  childbirth."  A  serous 
cholecystitis,  passing  off  in  a  few  hours,  causes  only  slight  dis- 
comfort, which  is  felt  as  a  light  pressure  in  the  region  of  the 
gall-bladder  and  as  a  moderate  cramp  of  the  stomach.  An 
acute  purulent  inflammation  of  the    gall-bladder   excites  violent 

67 


6S  GALLSTONE  DISEASE. 

pains,    especially  if  the   outer   coat  of  the   gall-bladder  and  the 
neighboring  peritoneum  participate  in  the  inflammation. 

Whilst  in  the  first  case  the  examining  hand  excites  only  a 
slight  sensitiveness  to  pressure,  it  is  in  the  latter  kind  of  chole- 
cystitis scarcely  possible  to  undertake  an  examination  ;  the  gall- 
bladder region  is  so  excessively  painful  that  even  the  softest 
touching  of  the  patient  occasions  the  greatest  tortures.  If  the 
stone  is  driven  into  the  cystic  duct,  then  there  is  added  to  the 
pain  of  the  inflammation  that  of  the  obstruction,  and  I  can  almost 
believe  that  the  pain  which  the  stone  excites  in  the  spiral  cystic 
duct  is  even  greater  than  if  it  passes  the  papilla  of  the  duodenum. 
If  the  stones  are  seated  only  in  the  inflamed  gall-bladder,  then 
the  principal  pain  is  experienced  in  the  right  hypochondrium. 
The  pain  radiates  in  the  meantime  also  into  the  breast  and  the 
back,  especially  then  if  the  concretions  are  driven  into  the  bile 
ducts.  If  these  are  in  the  common  duct,  then  is  also  the  epigas- 
trium, more  rarely  the  left  hypochondrium,  painful  to  pressure. 
With  unusual  frequency  a  gallstone  colic  is  regarded  as  an  ordi- 
nar\'  cramp  of  the  stomach.  That  it  is  often  very  difficult  to  dis- 
tinguish the  pains  which  are  excited  by  stomach  affections,  es- 
pecially b}-  ulcus  ventriculi,  from  gallstone  colic,  is  proven  to  me 
by  the  fact  that  I  have  operated  upon  a  series  of  cases  which  had 
been  submitted  to  a  strict  "ulcer  cure"  by  the  most  eminent 
stomach  specialists,  whilst  the  presence  of  gallstones  had  been 
with  positiveness  denied.  It  may  possibly  be  that  the  patients, 
when  they  were  under  the  care  of  the  stomach  specialists,  actu- 
ally suffered  from  an  ulcer  of  the  stomach,  whilst  the  already 
existing  cholelithiasis  was  latent.  It  may  be  that  the  gallstones 
first  originated  later.  At  a  gallstone  operation  it  is  surely  not 
an  easy  matter  to  determine  the  presence  of  a  synchronous  ulcer 
of  the  stomach  or  duodenum,  or  to  prove  its  non-existence. 
Where  epigastric  adhesions  exist  or  the  infiltrated  ulcer  is  acces- 
sible to  palpation,  as  is  the  case  with  ulcers  of  the  anterior  wall 
and  lesser  curvature  of  the  stomach,  the  certain  demonstration 
of  the  ulcers  occasions  no  marked  difficulties;  yet  we  must  re- 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  69 

member  that,  for  example,  adhesions  to  pylorus  and  duodenum 
may  arise  from  the  gall-bladder  or  the  inflammatory  processes 
there  going  on.  Therefore,  it  always  remains  questionable 
whether  the  peripyloritis  arises  from  an  ulcer  of  the  stomach  or 
from  a  cholecystitis,  even  when  we  have  found  gallstones  in  large 
number.  If  also  the  differential  diagnosis  between  ulcer  of  the 
stomach  and  cholelithiasis,  even  after  widely  opening  the  abdo- 
men, is  scarcely  to  be  made,  then  we  cannot  be  surprised  that  a 
differentiation  of  that  sort  occasions,  especially  for  the  practising 
physician,  many  difficulties.  If  one  has  to  do  with  the  haemor- 
rhages from  stomach  and  bowel  so  characteristic  of  ulcer,  and  if 
one  finds  gallstones  in  the  stools  after  the  professed  cramp  of  the 
stomach,  or  if  this  latter  is  attended  by  jaundice  or  liver  enlarge- 
ment, then  there  will  be  no  doubt  with  what  disease  we  have  to 
deal.  But  it  is  by  no  means  rare  that  cholelithiasis  is  associated 
with  ulcer  of  the  stomach,  by  \vhich  fact  the  difficulties  of  a  dif- 
ferential diagnosis  are  greatly  increased. 

For  the  differentiation  of  the  two  diseases  under  consideration, 
all  authors  of  the  highest  rank  have  cited  the  kind  of  pain.  A 
gallstone  patient  has  indeed,  for  the  most  part,  lighter  pains  after 
lobster  mayonnaise  and  cucumber  salad  than  after  an  entirely 
unirritating  diet,  as  after  soup  and  milk ;  but  it  is  a  fact  that  he 
frequently  for  a  long  time,  even  on  a  heavy  diet,  need  feel  noth- 
ing of  his  gallstones,  whilst  he  frequently  has  discomfort  with  a 
very  unirritating  diet.  The  pain  of  ulcer  is  more  dependent  upon 
the  quantity  and  quality  of  the  food,  and  begins  immediately  or 
a  half-hour  after  eating.  Further,  special  attention  should  be 
called  to  the  fact  that  the  pain  of  ulcer  rarely  occurs  with  an 
empty  stomach  or  at  night,  whilst  precisely  the  gallstone  colic 
pain  occurs  in  the  night  on  an  empty  stomach  about  five  hours 
after  eating.  I  explain  this  occurrence  with  gallstone  colic  as 
follows  :  According  to  the  remarks  made  concerning  the  patho- 
logical anatomy  of  cholelithiasis  the  gallstone  colic  arises  from 
an  inflammatory  swelling  of  the  mucous  membrane  of  the  gall- 
bladder which  invades  the  cystic  duct  and  occludes  it.     Accord- 


70 


GALLSTONE  DISEASE. 


ing  to  the  numerous  experiments  which  I  have  made  with  my 
gall-bladder  fistula  operations,  the  gall-bladder  is  to  be  regarded 
as  a  reservoir  which  takes  up  the  bile,  which  is  not  immediately 
excreted  into  the  intestine,  where  it  should  take  part  in  the  di- 
gestive processes.  If  one  eats  at  regular  intervals,  as  in  the  day 
is  the  custom,  then  little  bile  flows  into  the  gall-bladder,  but  puts 
itself  at  the  disposition  of  the  intestine  ;  it  flows  directly  through 
the  choledochus  into  the  duodenum.  During  the  night,  in  which 
one  sleeps  and  usually  eats  nothing,  it  collects  in  the  gall- 
bladder. If  a  bile  fistula  also  exists,  such  as  the  surgeon  makes 
in  cholecystotomy,  then  one  observes  afterward,  as  I  frequently 
had  the  opportunity,  that  in  the  daytime  the  excretion  of  bile 
was  very  slight,  but  during  the  night  very  profuse.  Nothing  in- 
deed is  more  suited  to  give  rise  to  a  stasis  of  bile  in  the  gall- 
bladder than  irregular  and  frugal  eating.  The  stasis  gives  occa- 
sion to  the  inflammatory  swelling  of  tlie  cystic  duct,  and  thus  is 
explained,  perhaps,  the  beginning  of  gallstone  colic  about  mid- 
night. I  have  on  this  account  given  the  advice  to  gallstone 
patients  to  accustom  their  gall-bladders  to  a  regular  emptying, 
that  is,  to  eat  every  three  hours,  and  if  possible  to  add  a  late 
supper.  Although  I  know  that  the  frequent  occurrence  of  chole- 
liathiasis  in  the  female  sex  is  to  be  ascribed  to  well  determined 
causes  (costal  type  of  breathing,  unnecessary  clothing,  excessive 
lacing,  pregnancy),  yet  one  might  be  tempted  to  believe  that  the 
rarer  occurrence  of  cholelithiasis  with  men  might  depend  upon 
this,  that  he  does  not  go  to  bed  so  early,  and  many  times  very 
late,  after  the  real  German  manner,  brings  his  offering  to  the 
gods  Gambrinus  and  Bacchus,  and  frequently  expels  the  bile 
from  the  gall-bladder  by  a  late  midnight  meal.  Therefore  gall- 
stone disease  ought  to  be  a  disease  of  steady  husbands,  although 
I  cannot  establish  it  statistically.  Although  in  such  a  horribly 
painful  disease  such  a  jocular  and  hardly  scientific  observation 
may  scarcely  be  cited,  and  I  eagerly  take  to  myself  the  reproach, 
yet  I  have  gained  the  impression  that  a  late  supper  was  desirable 
for  gallstone  patients.     I  recommend  it,  and  naturally  only  after 


THE  SPFXIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  7 1 

years  will  be  able  to  report  in  the  case  of  my  patients  something 
regarding  the  action  of  such  night  cures. 

At  all  events,  gallstone  colics  occur  far  more  frequently,  inde- 
pendently of  meals,  than  the  pains  of  ulcers.  The  opinion  of 
Boas  that  the  pain  of  cholelithiasis  is  exquisitely  cra«mp-like, 
that  here  there  exists  an  especial  pressure-point  to  the  right  of 
the  spine  at  the  level  of  the  twelfth  dorsal  vertebra,  I  can  by 
no  means  confirm  with  my  experience.  The  pain  of  gallstone 
colic  can  likewise  be  boring,  burning,  nagging,  and  fixed  in  a 
well-defined  place,  as  the  pain  of  ulcer  of  the  stomach.  Only  in 
the  following  relation  do  we  find  a  landmark  for  differentiating 
the  two  kinds  of  pain.  The  pain  of  gallstone  colic  is  more  to 
the  right  and  localized  in  the  region  of  the  gall-bladder,  whence 
it  frequently  radiates  to  the  back  and  to  the  right  shoulder- 
blade  and  into  the  breast.  But  not  infrequently  it  bores  and 
nags  in  a  very  circumscribed  place  under  the  right  rectus  abdo- 
minis without  its  assuming  a  radiating  character.  If  it  is  also 
experienced  as  a  cramp  of  the  stomach,  then  a  gentle  palpation 
of  the  upper  part  of  the  abdomen  shows  that  the  middle  line  is 
free  from  pain  and  that  the  greatest  sensitiveness  is  localized 
where  the  gall-bladder  usually  lies.  On  the  other  hand,  the 
pain  of  ulcer  almost  always  leaves  the  right  side  of  the  abdomen 
free,  and  is  localized  especially  in  the  middle  line  or  the  left 
hypochondrium. 

We  see,  therefore,  that  from  the  kind  of  pain  it  is  not  easy  to 
distinguish  the  two  conditions  assumed.  Far  better  landmarks 
are  in  this  respect  given  us  by  the  course  of  the  disease  and 
the  result  we  obtain  by  an  examination  of  the  contents  of  the 
stomach.  In  cholelithiasis  one  may  feel  weeks  and  months  long 
perfectly  well  ;  one  may  bear  the  heaviest  diet,  drink  sec  and 
beer,  to  be  then  suddenly  attacked  by  his  colics,  during  very 
temperate  living,  after  meal  soup  and  acorn  cacao.  One  seldom 
observes  the  like  in  ulcer  of  the  stomach.  Now  as  to  the  state 
of  the  stomach's  contents,  it  is  well  known  that  increase  of  the 
hydrochloric  acid  formation  is  frequently  observed  in  ulcer  of  the 


72 


GALLSTONE  DLSEASE. 


stomach.  With  gallstone  disease  one  finds  either  normal  or  de- 
ficient hydrochloric  acid,  unless  that  there  arise  severe  stomach 
symptoms  not  owing  to  adhesions  and  stenosis  at  the  pylorus. 

Very  frequently  at  my  operations  I  have  observed  conditions 
of  that  sort  :  the  patient,  severely  plagued  by  colics,  becomes 
severely  ill  through  the  trouble  in  the  stomach,  due  to  the  peri- 
pyloritis,  which  is  the  consequence  of  calculous  cholecystitis. 
Yes,  indeed,  without  a  mechanical  hindrance  at  the  pylorus  ex- 
isting, that  is  in  the  absence  of  adhesions,  a  weakness  of  the 
motor  functions  of  the  stomach  can  develop  in  cholelithiasis, 
which  is  still  further  increased  by  drinking  carbonated  waters. 
That  which  is  applicable  to  the  pain  of  ulcer  is  also  applicable 
in  gastralgia  and  neuralgia  of  the  stomach.  I  will  by  no  means 
deny  its  existence,  but  I  am  confident  :  TJic  niajority  of  tJic  pains 
which  arc  called  cramps  of  tJic  stomach  arc  gallstone  colics.  If 
one  examines  carefully,  then  one  finds  with  the  alleged  cramp 
of  the  stomach  always  a  sensitiveness  to  pressure  of  the  lower 
liver  border  in  the  region  of  the  gall-bladder,  and  through  this 
alone  we  are  in  position  to  make  a  differential  diagnosis.  Further, 
the  different  kinds  of  neuralgias  which  have  their  seat  in  the 
right  upper  part  of  the  abdomen  come  under  consideration  in 
their  differential  diagnostic  relations.  Still,  even  simple  inter- 
costal neuralgias  have  been  held  to  be  gallstone  colics.  A  patient 
was  sent  to  me  for  a  gallstone  operation  who  had  lead  cohc  ;  he 
was  an  employing  painter,  and  showed  on  his  gums  the  well- 
known  lead  line  and  the  peculiar  drawing-in  of  the  abdomen.  Of 
course,  he  remained  unoperated  upon.  Such  mistakes  may 
occur  oftener  than  one  believes.  One  should  give  on  this  ac- 
count exact  attention  to  the  lead  line  in  men  who  have  colic  in 
the  right  hypochondrium,  and  should  not  fail,  in  taking  the 
amnesis,  to  determine  the  occupation  of  the  patient.  With 
appendicitis  acute  cholecystitis  can  easily  be  confounded,  espe- 
cially then,  if  the  appendix,  as  I  have  seen  it  in  my  numerous 
operations  for  epityphlitis,  is  turned  upwards,  so  that  it  can  with 
its   extremity  reach  the  lower  liver  border.     In  fact  there  exists, 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  73 

indeed,  between  the  pathologico-anatomical  processes,  which  take 
place  in  acute  cholecystitis  and  acute  ^ippendicitis,  no  great  differ- 
ence. Here,  as  there,  we  have  before  us  a  hollow  organ  lined 
with  mucous  membrane,  the  contents  of  which  is  infected,  and 
whose  excretory  ducts  are  obstructed.  The  patients  vomit  ; 
they  complain  of  severe  pain,  and  flatus  ceases  to  pass.  Now, 
if  in  appendicitis  the  pain  is  localized  more  upward,  and  by 
cholelithiasis  more  downwards,  then  it  is  in  fact  not  easy  to 
separate  the  two  conditions  from  one  another.  And  if  now, 
indeed,  the  two  fearful  diseases  attack  the  man  at  the  same  time, 
naturally  one  diagnosticates  that  disease  which  occasions  the 
most  pronounced  symptoms,  and  that  is  appendicitis. 

Intestinal  colics  in  the  region  of  the  transverse  colon  are  diffi- 
cult to  distinguish  from  gallstone  colics  of  slight  degree.  I 
have  known  cases  which  were  treated  for  years  as  intestinal 
colics,  since  the  pains  actually  ceased  with  the  passage  of  flatus 
and  stools.  It  is,  however,  also  for  gallstone  colic  characteristic  ; 
just  as  soon  as  flatus  passes,  the  gallstone  colic  pain  ceases,  even 
then  when  no  adhesions  exist  betiveen  the  colon  and  gall-bladder. 
All  gallstone  colics  are  not  cramp-like,  nor  do  they  radiate  to  the 
back  ;  often  the  pain  is  only  moderate  and  stabbing-,  and  not  at  all 
distinguishable  from  intestinal  colic,  if  one  cannot  by  the  ex- 
amination prove  that  the  lower  liver  border  is  sensitive  to  pres- 
sure. A  confusion  of  acute  cholecystitis  with  ileus  is  possible, 
since  the  former  can  run  its  course  under  the  guise  of  an  ob- 
struction of  bowels.  The  circumscribed  peritonitis  on  the  gall- 
bladder, pericholecystitis  involves  by  preference  the  omentum 
and  intestine  in  participation  in  the  disease.  The  intestinal  wall 
is  in  this  place  locally  paralyzed,  and  constipation  and  vomiting 
appear.  Since  the  intestines  become  distended,  and  by  this 
make  difficult  the  examination  of  the  abdomen,  naturally  one 
may  easily  fail  to  recognize  the  cholecystitis  as  the  cause  -of  the 
symptoms  of  ileus.  Whether  there  is  a  liver  colic  of  nervous 
origin  the  internists  must  decide  ;  it  is  difficult  for  me  as  a  sur- 
geon to  believe  in  such  a  disease.     The  cases  which  came  to  me 


74 


GALLSTONE  DISEASE. 


have  concerned  anemic  women,  with  periodic  appearing  colic  in 
the  right  hypochondrium.  Since  jaundice  and  enlargement  of 
the  liver  was  wanting,  and  other  severe  symptoms  involving  the 
nervous  system  were  present,  the  patients  had  been  treated  for  a 
long  time  by  their  doctors  for  nervous  liver  colic,  yet  I  found 
always  gallstones  in  an  inflammed  gall-bladder  or  numerous  ad- 
hesions. By  operation  the  nervous  liver-colic  was  cured.  I  will 
not  absolutely  deny  the  possibility  of  such  a  disease,  yet  the 
practitioner  does  well  if  he  is  not  too  liberal  with  this  diagnosis. 

With  peritonitis  gallstone  disease  has  not  rarely  been  confused, 
for  in  both  diseases  occur  collapse,  excessive  sensitiveness  to 
pressure  of  the  belly,  rapid  pulse  and  elevation  of  temperature. 
In  general,  with  peritonitis  the  pulse  is  frequent  and  small,  the 
fever  usually  high  ;  yet  I  have  seen  enough  cases  of  purulent 
peritonitis  in  which  the  pulse  remained  good  and  the  temperature 
showed  no,  or  but  slight,  elevation.  More  weight  is  to  be  laid 
upon  the  type  of  breathing,  which  in  peritonitis  easily  becomes 
purely  costal,  whilst  in  gallstone  colic  the  diaphragm  still  re- 
mains subject  to  a  visible  movement.  Finally,  the  proof  of  in- 
doxyl  in  the  urine  is  said  to  speak  against  cholelithiasis  and  for 
peritonitis  or  appendicitis. 

The  pain  of  kidney  colic  does  not  always  run  in  the  typical 
manner,  in  that  it  radiates  along  the  ureter  to  the  bladder.  It  is 
also  for  the  most  part  felt  in  the  lumbar  region  ;  in  this  way,  then, 
confusion  with  gallstone  colic  may  occur.  One  examines  care- 
fully the  urine,  determines  its  quantity  and  color,  and  by  palpa- 
tion gives  heed  to  how  the  region  of  the  gall-bladder  and  the 
lower  liver  border  appear  to  the  palpating  hand.  If  a  purulent 
process  develops  on  the  posterior  surface  of  the  gall-bladder,  it  may 
then,  if  we  have  in  so  doing  only  the  kind  of  pain  in  view,  often 
be  impossible  to  distinguish  this  from  a  paranephritic  suppura- 
tion. 'Since  the  results  of  palpation  are  the  same,  we  can  fre- 
quently onl}'  b)'  the  amnesis  come  upon  the  right  trail. 

Ulcer  of  the  stomach,  intestinal  colics,  appendicitis,  kidney 
colics,  ileus,  and  peritonitis., — all  these  diseases  and  disease  symp- 


THE  SPECIAL  DIAGNOSIS  ()¥  CIIDLEIJTIIIASIS.  75 

toms  have  been  confounded  with  gallstone  disease.  But,  then, 
other  disease  processes  also  enter  into  consideration.  Syphilis 
of  the  liver,  as  I  once  could  very  closely  observe,  occasions  in- 
flammatory processes  in  the  gall-bladder  which  progress  with 
pain  and  jaundice,  and  are  not  at  all  to  be  distinguished  from  the 
ordinary  cholecystitis.  The  gastric  crises  of  locomotor  ataxia, 
and  by  no  means  rarely  the  hernia  of  the  linea  alba  above  the 
navel,  may  lead  the  physician  to  the  assumption  that  gallstone 
disease  exists.  Whoever,  nevertheless,  gives  the  necessary  at- 
tention to  the  amnesis  and  the  examination,  and  with  regard 
to  the  local  disease  does  not  forget  the  whole  sick  man,  will,  in- 
deed, always  come  to  the  correct  diagnosis.  The  hernia  of  the 
linea  alba  always  discloses  to  the  examination  the  pain  in  an 
extremely  defined,  circumscribed  place.  And  although  the 
cramps  of  the  stomach,  w^hich  occur  from  it,  exactly  resemble 
gallstone  colics,  yet  there  is  wanting  the  characteristic  pain  on 
pressure  in  the  gall-bladder  region.  If  the  hernia  is  not  yet 
fully  developed,  if  it  is  not  yet  to  be  felt  as  that  well-known 
little  tumor  in  the  linea  alba,  deceptions  are  then  nevertheless 
only  rarely  possible,  because  the  pain  on  palpation  remains 
always  exactly  localized  in  the  median  line.  Of  course  in  such 
cases  also  an  ulcer  of  the  stomach  may  be  concealed  behind,  or 
adhesions  between  stomach  and  liver,  which  ow^e  their  existence 
to  an  ulcer,  finally  tuberculous  and  carcinomatous  processes, 
especially  at  the  pyloric  orifice  of  the  stomach. 

What  physician  does  not  err  in  the  field  of  the  diagnosis  of 
the  disease  processes  occurring  in  the  upper  portion  of  the  ab- 
domen ?  The  abdominal  changes  below  the  navel  permit  a 
diagnosis  a  hundred  times  easier  than  those  above  the  same, 
since  it  is  permitted  to  the  gynaecologist  to  employ  the  vagina 
and  the  rectum  as  welcome  openings  for  making  a  good  diagno- 
sis. Unfortunately  sufficient  use  is  not  yet  always  made  by  the 
physician  of  this  intelligent  arrangement  of  nature,  as  the  nu- 
merous diagnoses  of  haemorrhoids  prove,  which  on  more  careful 
examination   disclose   carcinoma.     Vastly  more   difficult  for  the 


'J^  GALLSTONE  DLSEASE. 

physician  becomes  the  differential  diagnosis  if  jaundice  associates 
itself  with  the  pains  arising  in  the  right  hypochondrium.  One 
has  been  wont  to  think  that  the  appearance  of  jaundice  actually 
cleared  up  the  case.  For  many  cases  it  is  so,  but  often  the 
appearance  of  jaundice  in  its  diagnostic  relations  gives  us  many 
a  hard  nut  to  crack,  for  the  appearance  of  jaundice  by  no  means 
proves  that  the  stone  has  reached  the  common  duct ;  it  can  be 
solely  the  expression  of  an  inflammatory  process,  which  has 
extended  from  the  mucous  membrane  of  the  gall-bladder  to  that 
of  the  bile  ducts. 

I  need  not  at  length  enter  into  the  differentiation  of  inflamma- 
tory from  the  real  lithogenous  jaundice,  since  I  have  already  in 
a  former  lecture  given  the  information  necessary  for  it.  Icterus 
occurs  with  all  possible  diseases  of  the  liver,  and  the  aim  of  the 
diagnosis  will  be  to  exclude  all  liver  diseases  Avhich  develop 
with  pain  and  enlargement  of  the  liver.  I  refer  in  this  respect 
only  to  suppurating  echinococcus  cyst,  abscess  of  the  liver  and 
pyaemic  processes  in  the  liver.  The  previous  history  of  the 
case  cannot  get  by  any  means  enough  attention  in  the  diagnosis 
of  such  cases.  It  cannot  be  my  duty  to  describe  the  entire 
differential  diagnosis  of  liver  affections,  and  I  refer  you  in  this 
respect  to  the  text-  and  hand-books  on  internal  medicine. 

No  organ  in  the  abdomen  is,  excepting  the  stomach  and  liver, 
so  injured  by  gallstone  disease  as  the  pancreas.  Simple  chole- 
cystitis can  occasion  marked  changes  in  the  pancreas,  which 
may  persist  long  after  the  gallstone  disease  is  cured.  I  refer  in 
this  connection  to  chronic  interstitial  pancreatitis,  which  b)^  prefer- 
ence attacks  the  head  of  the  pancreas  and  leads  to  compression 
of  the  common  duct.  The  same  causes  which  induce  the  stone 
disease  in  the  gall-bladder  may  lead  to  the  formation  of  concre- 
tions in  the  pancreas,  lithiasis  pancreatica.  The  symptom  com- 
plex which  the  passage  of  a  pancreatic  stone  into  the  intestine 
occasions  will  naturally  be  the  same  as  that  which  is  occasioned 
by  a  gallstone  passing  the  papilla  of  the  duodenum  :  there  occurs 
colic,  fever,  jaundice.      W^ith  pancreas  stones  the  pains  are  said 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  77 

to  rage  more  in  the  pit  of  the  stomach  and  the  left  hypochon- 
drium  ;  yet  I  am  incHned  to  doubt  if  one  can,  from  the  nature  of 
the  pain,  distinguish  gallstone  colics  from  pancreas  colics.  At 
all  events,  pancreas  stones  occur  so  rarely  that  they  play  no 
noteworthy  role  in  differential  diagnosis.  But  not  only  lithiasis 
of  the  pancreas,  but  also  other  affections  of  the  pancreas  may 
give  occasion  for  confusion  with  cholelithiasis.  Very  recently 
Morian  in*  Essen  a  Ruhr  has  published  a  case  of  necrosis  of 
the  pancreas  which,  in  the  beginning,  developed  entirely  like 
cholelithiasis. 

I  consider  it  impossible  to  confound  pancreas  cysts  with 
dropsy  of  the  gall-bladder.  It  may  easily  occur  that  one  takes 
an  echinococcus,  which  develops  in  the  liver  next  to  the  gall- 
bladder, for  a  dropsy  of  the  gall-bladder.  Although  I  admit 
that  the  pain  of  gallstone  colic  is  often  experienced  in  places 
which  lead  the  physician  to  think  rather  of  appendicitis,  ulcer 
of  the  stomach,  etc.,  than  of  cholelithiasis,  and  although  I  can 
conceive  of  false  diagnosis  in  cases  where  no  gall-bladder  tumor 
is  found,  yet  an  error  can  and  ought  not  to  occur  if  the  practi- 
tioner, by  his  examination,  discovers  a  tumor  in  the  right  hypo- 
chondrium  whose  form  and  movement  carries  with  it  the  char- 
acteristic signs  of  a  gall-bladder  tumor.  Usually  it  is  easy  to 
decide  that  the  previously  discovered  tumor  is  actually  the  gall- 
bladder. 

We  notice,  first  of  all,  its  situation.  In  obese  persons  and 
men  with  rigid  abdominal  walls  the  determination  of  the  site  of 
the  gall-bladder  is  often  impossible,  whilst  with  spare  patients, 
and  women  who  have  borne  children,  the  organ  lies  so  directly 
under  the  abdominal  walls  that  one  sees  not  only  its  prominence, 
but  also  observes  how,  with  the  liver,  it  follows  the  respiratory 
movements  of  the  diaphragm  ;  the  larger  and  the  more  distended 
the  gall-bladder  is,  so  much  the  more  will  it  be  visible.  The 
seldomer    an    inflammatory    process    has    existed    in    the    gall- 


*  Miinch.  med.  Wochenschrift,  No.  11,  1899. 


78  •  GALLSTONE  DISEASE. 

bladder,  so  much  the  easier  do  its  walls  distend,  and  yield  to  the 
pressure  of  the  secretion  retained  in  the  gall-bladder.  If  the 
gall-bladder  has  often  been  the  seat  of  inflammation,  then  its 
walls  become  rigid,  their  elasticity  diminishes,  and  on  this  ac- 
count there  often  occurs  only  a  shght  tumor  formation,  ev^en  in 
case  of  a  severe  existing,  acute  purulent  cholecystitis.  The  situa- 
tion of  the  gall-bladder,  moreover,  depends  entirely  whether  the 
li\'er  has  undergone  any  changes  in  form  or  volume  (lacing-liver, 
enlargement  of  liver),  or  whether,  by  adhesions,  it  is  hindered 
from  taking  its  usual  position  in  the  abdominal  cavity.  Is  the 
first  the  case,  we  meet  in  constricted  liver  the  gall-bladder  often  in 
situations  in  which  its  presence  is  quite  surprising  to  us ;  in 
deeply  dependent  liver  we  find  it  even  immediately  over  Pou- 
part's  ligament.  The  more  the  liver  is  enlarged,  so  much  further 
downwards  in  the  abdomen  will  we  meet  with  the  gall-bladder. 
In  acute  cholecystitis,  nevertheless,  is  an  enlargement  of  the 
liver  rare,  and  on  this  account  is  the  displacement  of  the  gall- 
bladder by  constricted  liver  in  acute  cholecystitis  more  frequent 
than  by  general  enlargement  of  the  liver.  If  the  cholecystitis  is 
complicated  by  cholangitis,  then  we  have  to  reckon  with  a  general 
enlargement  of  the  liver.  Moreover,  such  gall-bladders  as  are 
not  distended  by  inflammation,  but  can  be  regarded  as  normal, 
have  a  very  different  form  ;  scarcely  does  one  gall-bladder  re- 
semble another.  It  is  often  stretched  out  like  a  cucumber, 
spherical  as  an  apple,  as  small  as  a  cherry.  Usually  we  feel  the 
gall-bladder  under  the  right  rectus  abdominis  or  its  external 
border  ;  exceptions  are  not  rare.  Thus,  I  recall  several  cases  in 
which  I  found  the  gall-bladder  tumor  in  the  median  line,  or  even 
under  the  left  rectus  muscle.  Often  it  was  not  to  be  felt  despite 
its  distension  with  pus,  and  lay  very  high  up  under  the  liver. 
If  one  opens  the  abdomen  in  these  cases,  then  must  one  fre- 
quently search  a  long  time  for  the  gall-bladder  before  one  finds 
it.  It  is  for  the  practitioner  extremely  important  to  know  that 
even  a  severe  acute  einpyema  of  the  gall-bladder  can  exist  without 
that  one  is  in  position  to  feel  the  gall-bladder  as  a  tumor.      Often 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS. 


79 


one  finds  only  an  increased  resistance  in  the  region  of  the  gall- 
bladder, and  many  times  one  feels  not  a  trace  of  the  gall-bladder, 
but  can  excite  severe  pain  if  he  practices  the  bimanual  examina- 
tion, that  is,  elevates  the  liver  from  behind  forward  and  presses 
it  against  the  ribs.  Let  us  imagine  a  typical  fresh  case  of  chole- 
cystitis with  normal  liver  and  still  preserved  dilatability  of  the 
gall-bladder  in  a  woman  with  easily  depressed  abdominal  walls. 
Then  the  physician  comes  upon  a  long  ovoid  or  half-round 
tumor,  which  permits  one  to  define  its  limits  at  the  sides  and 
below,  and  not  rarely  does  one  succeed  in  determining  the  tran- 
sition of  the  tumor  into  the  liver.  Especially,  then,  if  the  infec- 
tion is  extinguished,  if  one  has  to  do  only  with  a  dropsy  of  the 
gall-bladder,  is  demonstration  of  that  kind  easily  possible.  One 
commonly  thinks  that  the  connection  of  the  tumor  with  the  liver 
may  be  demonstrated  by  percussion,  and  in  fact  it  is  possible  in 
many  cases  by  percussion  to  establish  this  relation  ;  but  by  no 
means  always.  I  would  strongly  advise  one  not  to  strictly  rely 
upon  the  data  of  percussion,  since  intestinal  coils  may  crowd 
themselves  above  the  fundus  of  the  gall-bladder  between  the  ab- 
dominal walls  and  liver,  so  that  we  observe  two  dull  regions,  of 
which  the  upper  belongs  to  the  liver  and  the  lower  to  the  gall- 
bladder, whilst  arising  from  the  intestine  a  zone  of  tympanitic 
resonance  pushes  in  between,  the  interpretation  of  which  does 
not  easily  occur  to  even  the  best  examiner.  At  least  one  does 
not  readily  think  the  lower  dull  region  belongs  to  the  gall- 
bladder, since  above  it  tympanitic  resonance  is  to  be  demon- 
strated. It  is  not  always  easy  to  distinguish  gall-bladder  tumors 
from  tumors  of  the  pylorus,  omentum,  colon,  etc.  They  are  all 
often  movable  and  follow  the  respiratory  movements  of  the  dia- 
phragm, although  not  in  the  extensive  degree  which  is  peculiar 
to  gall-bladder  tumors.  The  following  procedure  serves  for  the 
differentiation  : 

If  one  causes  the  patient  to  breathe  deeply,  then  the  tumor  of 
the  gall-bladder  descends.  If  one  grasps  it  at  the  end  of  inspi- 
ration, and  causes  the  patient  now  to   expire,  then   one  cannot 


8o  GALLSTONE  DISEASE. 

hold  the  tumor  fast ;  it  ascends  again  with  the  expiration.  But 
it  is  possible  to  hold  tumors  of  the  pylorus,  colon,  omentum, 
provided  they  have  formed  no  adhesions  with  the  liver.  Just  as 
soon  as  this  is  the  case,  they  also  follow,  even  as  the  gall- 
bladder, the  respiratory  movements  of  the  diaphragm.  More- 
over, all  these  diagnostic  scruples  have  little  importance  ;  what 
physician  does  not  advise  operation  on  the  demonstration  of  a 
tumor  in  the  abdomen  which  always  is  apparent  and  is  uninflu- 
enced by  medical  treatment  !  And  as  much  more  praiseworth}' 
as  it  is  if  we  previously  make  an  exact  diagnosis,  yet  there  re- 
mains wath  the  impossibility  of  recognizing  in  all  cases  the  origin 
of  the  tumor  the  exploratory  incision,  which,  aseptically  done, 
almost  always  brings  advantage  and  scarcely  ever  occasions 
harm. 

We  have  mentioned  above  the  mobility  of  gall-bladder  tumors. 
In  spare  patients  the  downward  and  upward  movement  of  the 
tumor,  corresponding  to  the  movements  of  the  diaphragm,  is 
easy  to  be  seen.  If  the  patients  have  severe  pains,  then  they 
render  the  right  side  of  the  diaphragm  motionless  ;  they  breathe 
superficially,  and  through  this  the  movement  of  the  tumor  of  the 
gall-bladder  becomes  indistinct.  If  adhesions  to  the  gall-bladder 
are  present,  the  mobility  of  the  tumor  ceases  or  becomes  greatly- 
limited.  Often  the  gall-bladder  is  walled  in  by  adhesions,  so 
that  any  sort  of  displacement  becomes  impossible. 

Characteristic  of  gall-bladder  tumors  are  the  lateral  pendu- 
lum-like movements,  which  one  can  impress  up  the  organ.  A 
large  distended  gall-bladder  permits  itself  to  be  pushed  here  and 
there  in  the  belly  so  much  the  more  extensively  if  the  liver  is 
movable,  as  is  in  women  who  have  been  frequently  confined, 
frequently  the  case.  If  it  is  more  fixed,  then  the  lateral  move- 
ments of  the  gall-bladder  are  less  extensive  ;  yet  one  observes 
clearly  how  the  center  of  motion  lies  upward  toward  the  neck  of 
the  gall-bladder.  Here  is  a  suitable  place  to  enter  upon  the 
differential  diagnosis  between  right-sided  movable  kidney  and 
tumor  of  the  gall-bladder;  frequently  have  patients  been  sent  to 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  8  I 

me  for  a  nephropexy  who  had  absolutely  no  movable  kidney, 
but  in  whom  existed  only  a  dropsy  of  the  gall-bladder.  They 
assert  that  upon  distending  the  colon  with  air,  tumors  of  the  kid- 
ney (hydronephrosis)  disappear,  that  is  to  say,  come  to  lie  behind 
the  colon,  wdiilst  gall-bladder  tumors  lie  in  front  of  the  colon,  at 
most  push  more  upward.  This  is  true  of  many  cases,  yet  one 
cannot,  by  reason  of  this  examination,  make  an  exact  diagnosis. 
The  colon  can  also  lie  in  front  of  the  gall-bladder  and  cause  it  to 
disappear.  Much  more  important  for  the  differential  diagnosis 
is  the  characteristic  sensation  which  one  experiences  with  the 
reposition  of  a  movable  kidney  :  as,  with  a  slap,  the  movable 
kidney  darts  upward  and  backward,  often  to  remain  lying  in  the 
spot,  whilst  one  can  push  the  gall-bladder  tumor,  if  it  is  not 
fixed,  also  upward  and  backward  ;  yet  one  observes,  in  so  doing, 
that  it  returns  to  the  same  spot  immediately  behind  the  anterior 
abdominal  wall. 

If  the  patient  is  brought  to  bed,  then  the  movable  kidney,  once 
replaced,  remains  almost  always  in  the  newly  appointed  place — 
that  is,  behind  in  its  normal  situation,  the  gall-bladder  lies  always 
immediately  behind  the  abdominal  walls.  Lateral  movements 
may  be  impressed  upon  a  movable  kidney,  but  they  are  not 
pendulous.  The  gall-bladder  has  a  fixation  point  at  its  superior 
end  ;  the  movable  kidney  has  no  such  peculiarities.  A  further 
peculiarity  of  the  gall-bladder  tumor  shows  itself  on  distension 
of  the  stomach  with  air.  With  this  the  tumor  of  the  gall-bladder 
is  crowded  more  to  the  right  and  upward  ;  also  forward,  so  that 
it  presents  itself  to  us  more  clearly.  The  result  of  the  disten- 
sion of  the  stomach  is,  however,  far  from  so  accurate  as  the 
results  which  we  attain  by  delicate  and  careful  palpation  with 
the  hand.  The  two  chief  symptoms  of  cholecystitis,  the  colicky 
pain  and  the  tumor  of  the  gall-bladder,  associate  themselves 
with  still  other  symptoms,  which  can,  however,  absolutely  dis- 
appear. 

I.  Fever. — In  light  serous  inflammations  it  can  be  absolutely 
absent,  or  fluctuate  in  narrow  moderate  limits.  In  the  real  pur- 
7 


82  GALLSTONE  DLSEASE. 

ulent  form  it  reaches  a  higher  degree,  and   then   it  assumes  the 
type  of  septic  fever. 

2.  Icterus. —  It  is  absent  in  the  vast  majority  of  cases  ;  when 
it  does  occur,  it  indicates  a  participation  of  the  Hver  ducts  in  the 
inflammation,  also  cholangitis.  In  cholangitis  diffusa  the  jaun- 
dice is  usually  very  pronounced,  the  entire  capsule  of  the  liv^er 
tender,  the  general  health  impaired.  The  patients  impress  one 
frequently  as  thoroughly  septic. 

3.  Enlargement  of  the  Spleen. — As  in  all  infectious  pro- 
cesses, so,  in  cholecystitis,  is  enlargement  of  the  spleen  not  rarely 
an  associated  condition. 

4.  Albumin  Excretion  in  Urine. — Whilst  it  for  the  most  part 
is  massed  in  the  quickly  passing  forms  of  cholecystitis,  it  can  in 
the  severer  forms  assume  a  serious  degree. 

5.  Enlargement  of  the  Liver. — It  is  in  pure  cholecystitis 
relatively  rare;  frequently  it  is  wrongly  diagnosticated,  since  the 
enlarged  gall-bladder  and  the  oedematous  swelling  of  its  sur- 
roundings, especially  the  inflammatory  infiltration  of  the  omen- 
tum, simulate  an  enlargement  of  the  liver.  If  jaundice  appears, 
then  the  enlargement  of  the  liver  is  not  always  demonstrable. 
If  the  jaundice  passes  off  quickly,  the  enlargement  of  the  liver 
may  be  wanting. 

Concerning  the  diagnosis  of  acute  obstruction  of  the  common 
duct,  of  the  gallstone  colic,  well  known  from  a  long  time,  I  can 
be  very  brief,  since  the  symptomatology  is  familiar  to  every 
practitioner.  Like  a  lightning  stroke  from  a  clear  sky  the  colic 
often  sets  in  ;  many  times  gentle  forebodings  on  the  part  of  the 
stomach  give  warning  of  the  approaching  storm.  The  pain  be- 
gins in  the  right  hypochondrium,  radiates  toward  the  breast, 
toward  the  stomach,  and  often  toward  the  back  and  the  right  i 
shoulder-blade.  It  is  frequently  so  severe  that  women  who  have 
borne  with  wonderful  patience  the  pains  of  labor,  at  the  height 
of  the  colic  burst  out  into  loud  cries,  perceptible  at  a  distance,  and 
into  raving.  This  colic  depends,  without  doubt,  upon  the  ad- 
vance of  the   stone  through   the  tortuous  cystic  duct  and  the 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  8/ 

do  not  say  that  you  should  proceed  as  if  you  had  a  conversa- 
tion lexicon  in  hand  ;  such  certain  results  you  ought  not  to 
expect.  We,  however,  should  not  forget  that  each  single  gall- 
stone case  demands  for  itself  a  very  special  study  in  regard  to 
the  pathological  anatomy,  the  symptomatology  and  diagnosis. 
There  is  much  mental  labor  and  reflection  necessary  before  one 
recognizes  the  special  form  of  the  gallstone  disease  with  which 
the  patient  is  attacked,  and  I  would  deeply  lament  it,  if  my 
guide  should  give  occasion  to  schematizing.  The  table  is  like 
a  memorandum  tablet,  which  is  intended  to  acquaint  you  with 
the  most  prominent  symptoms  of  cholelithiasis  ;  it  would  be 
entirely  false  if  you  were  to  come  to  the  conclusion  that  by  it 
you  would  come  to  a  complete  insight  into  all  the  peculiarities. 
First,  very  gradually  you  will  learn  to  assemble  the  separate 
pictures,  and  then,  after  a  longer  time,  will  you  succeed  in  ob- 
taining a  conception  corresponding  to  the  reality  of  the  relation  of 
the  separate  forms  of  gallstone  disease.  I  am  myself,  in  spite 
of  my  rich  experience,  very  conscious  that  I  have  far  from 
learned  the  diagnosis  of  cholelithiasis  ;  and,  since  you  are  not  per- 
mitted to  be  present  at  gallstone  operations,  you  will  find  diffi- 
culties in  pressing  into  the  secrets  of  the  special  diagnosis  of 
cholelithiasis.  If,  however,  you  learn  to  distinguish  cholecystitis 
from  cholangitis,  and  to  know  the  landmarks  which  render  pos- 
sible the  differential  diagnosis  between  choledochus  obstruction 
by  stone  or  by  tumor,  if  you  can  determine  the  seat  of  the 
stone,  then  I  have  solved  the  problem  set  for  me  and  feel  myself 
richly  rewarded  for  the  pains  I  have  taken. 

It  cannot  possibly  be  my  purpose  to  describe  to  you  the  table 
from  beginning  to  end,  since  I  would  be  obliged  on  so  doing  to 
make  frequent  unnecessary  repetitions.  But  permit  me  at  least 
to  direct  your  attention  to  some  points  which,  according  to  my 
experience,  are  not  sufficiently  appreciated  by  the  practitioner. 
I  hav^e,  indeed,  already  said  that  which  is  necessary  concerning 
the  appearance  of  jaundice  in  gallstone  disease,  the  passage  of 
concretions,  and  the  relation  of  gall-bladder  tumors;  yet,  notwith- 


88  GALLSTONE  DISEASE. 

standing,  I  am  of  the  opinion  that  a  frequent  reference  to  these 
facts,  so  important  for  the  practising  physician,  is  very  neces- 
sary. 

1.  Icterus  is  wanting  almost  always  in  all  inflammatory  pro- 
cesses in  the  gall-bladder,  also  in  the  beginning  of  gallstone 
disease.  It  is  finally  time  that  the  physician  should  give  up  the 
view  that  icterus  belongs  to  cholelithiasis.  In  80  per  cent,  of 
all  gallstone  cases  icterus  is  absent. 

2.  Severe  attacks  of  pain,  which  are  not  to  be  distinguished 
from  gallstone  colics,  are  not  rarely  solely  occasioned  by  the 
presence  of  adhesions,  which  kink  the  cystic  duct.  Stones  may 
be  entirely  absent. 

3.  A  purulent  exudate  may  occur  in  the  gall-bladder  \vithout 
the  doctor  feels  a  tumor  of  the  gall-bladder.  Gall-bladders  in 
which  an  inflammation  has  already  often  occurred,  contract  so 
that  an  inflammation  can  no  longer  distend  them.  In  conse- 
quence they  are  not  to  be  felt  as  tumors. 

4.  The  passage  of  the  stone  in  the  feces  is  not  so  common  as 
one  has  heretofore  assumed,  for  most  colics  are  unsuccessful  ; 
that  is,  the  stone  remains  behind  in  the  gall-bladder. 

5.  A  pear-formed  or  ovoid  tumor  of  the  gall-bladder,  but 
slightly  or  not  at  all  painful,  without  jaundice  and  enlargement 
of  the  liver,  speaks  for  dropsy  of  the  gall-bladder. 

6.  A  more  or  less  painful  distended  tumor  of  the  gall-bladder 
speaks  for  an  empysema  of  the  gall-bladder. 

7.  A  painless  tumor  of  the  gall-bladder  with  a  high  degree 
of  jaundice  means  usually  an  obstruction  of  the  choledochus  by 
tumor. 

8.  A  hard,  nodular,  painful  tumor  of  the  gall-bladder  with- 
out jaundice  means  carcinoma  in  an  inflamed  gall-bladder. 

9.  A  hard,  nodular,  painful  tumor  of  the  gall-bladder  with 
jaundice  means  carcinoma  of  the  gall-bladder,  with  implication 
of  the  portal  glands. 

10.  In  acute  obstruction  of  the  choledochus,  which  is  usually 
ushered  in  by  an  inflammation  of  the  gall-bladder,  more  or  less 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  89 

pronounced  jaundice  appears,  which  quickly  recedes  so  soon  as 
the  stone  has  passed  the  papilla  of  the  duodenum. 

For  the  most  part,  wrong  diagnoses  occur  in  those  cases  in 
which  the  results  of  examination  are  negative — and  this  is  the 
case  in  a  great  number  of  cases — or  in  which  the  colics  are  not 
marked.  But  in  my  experience  also  wrong  diagnoses  are  not 
rare  in  sero-purulent  cholecystitis  and  chronic  obstruction  of  the 
choledochus  by  stone. 

Many  practitioners,  as  I  have  already  before  remarked,  are 
even  yet  of  the  opinion  that  intense  jaundice  always  accompanies 
chronic  obstruction  of  the  choledochus.  However,  in  it  the 
jaundice  is  frequently  sovlittle  marked  that  one  must  observe 
very  closely  in  order  to  recognize  it.  That  jaundice  can  be  com- 
pletely wanting,  despite  ak  large  stone  in  the  choledochus,  is  a 
fact  well  known  to  the  sujfgeon.  We  require  for  its  explanation 
only  to  recall  the  pathologico-anatomical  changes  which  occur  in 
chronic  obstruction  oytfee  choledochus.  The  stone  expelled 
from  the  gall-bladdef^vedges  itself  in  the  choledochus,  but  does 
not  pass  into  the  duodenum.  Behind  it  the  bile  collects  ;  the 
choledochus  dilates  ;  its4limen,  ordinarily  the  size  of  a  lead-pencil, 
attains  the  circumferenk^/of  a  finger,  even  of  the  duodenum. 
The  bile  flows  by  the  stone,  which  floats  about  in  the  dilated 
duct,  and  the  patient  may  completely  lose  his  jaundice.  But  the 
concretion — probably,  as^n  the  gall-bladder,  through  the  out- 
burst of  inflammatory  pr^esses — will  be  constantly  driven  into 
the  narrower  parts  of  the  jholedochus,  lying  nearer  the  intestine. 
Again,  icterus  appears,  ©iiis  variation  of  jaundice  is  very  char- 
acteristic of  chronic  chol^ochus  obstruction  by  stone.  Thus 
one  finds,  naturally,  the  stools  now  brown,  now  grey  ;  the  urine 
now  dark,  now  clear,  ^f  the  attacks  of  jaundice  increase,  then 
the  skin  gradually  assurae^  a  greyish-green  color,  a  very  char- 
acteristic appearance.  The  colics  are  frequently  accompanied  by 
fever,  which  may  assume  completely  the  character  of  malarial 
fever.  In  most  cases,  with  a  slight  chill,  an  elevation  of  temper- 
ature takes  place  ;  with  it  the  jaundice  increases  ;  on  the  succeed- 
8 


90 


GALLSTONE  DISEASE. 


ing-  day  the  fever  abruptly  falls.  Two,  three,  or  more  days,  the 
patient  feels  well,  while  the  jaundice  recedes  ;  then  the  fever 
again  appears,  so  that  one  may  imagine  a  malarial  fever.  This 
fever  is  certainl}-  not  a  reflex  fever,  but  is  of  infectious  nature. 
It  can  arise  without  the  occurrence  of  jaundice  or  colics  ;  but  if, 
indeed,  no  real  cramp  attacks  are  present,  then,  however,  the 
patient  feels  disagreeable  sensations  in  the  pit  of  the  stomach 
and  in  the  region  of  the  gall-bladder,  which  point  to  a  disease  of 
the  bile  ducts.  If  the  fever  changes  its  intermittent  character, 
and  if  it  exists  continuously  without  remission,  then  one  must  be 
very  careful  in  forming  a  prognosis,  since  a-  diffuse  purulent 
cholangitis,  thrombophlebitis,  or  liver  abscess  may  exist. 

The  chronic  obstruction  of  the  choledochus  by  stone  is  distin- 
guished from  the  obstruction  by  tumor  by  an  extensive  list  of 
landmarks.  Although  I  already  in  the  table,  and  also  in  a  pre- 
\aous  lecture,  have  given  the  most  important  differential  signs,  I 
will  once  more  yet  bring  out  the  differential  diagnostic  points, 
since  it  is  very  important,  in  relation  to  the  prognosis  and  treat- 
ment, to  be  right  well  informed  regarding  them.  I  will  premise 
that  it  is  not  always  possible  to  make  an  absolutely  certain  dis- 
tinction between  obstruction  of  the  choledochus  by  a  stone  and 
by  a  tumor,  especially  then  not,  if  carcinoma  of  the  choledochus 
is  complicated  by  a  stone  in  this  duct.  There  are  cases  in  which 
one  may  with  certainty  be  prepared  for  an  obstruction  by  stone 
and  one  finds  a  carcinoma.  On  the  other  hand,  patients  come 
for  treatment  who  are  so  ill  that  one  immediately  thinks  of  a 
carcinoma  and  one  finds  a  stone.  Although  I  also  admit  that 
the  differential  diagnosis  causes  often  very  great  difficulties,  yet 
I  can  by  numerous  cases  offer  proof  that  the  differentiation  of 
the  two  diseases  coming  under  our  attention  usually  succeeds. 
In  so  doing,  attention  must  be  given  to  : 

I.  Jaundice.  In  obstruction  of  the  choledochus  by  stone  it 
is  variable,  the  stools  often  brown,  often  grey  ;  in  obstruction  of 
the  choledochus  by  tumor  the  jaundice  is  generally  very  intense, 
seldom  variable,  and  accordingly  the  stools  are  almost  always 
clay-colored. 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  9 1 

2.  To  the  pains.  In  obstruction  of  the  choledochus  by  stone, 
pains  are  almost  never  wanting  ;  in  obstruction  by  a  tumor,  colicky 
attacks  belong  to  the  rarities. 

3.  To  the  results  of  palpation.  In  obstruction  of  the  chole- 
dochus by  a  stone  the  gall-bladder  is  usually  small  and  not  to 
be  felt ;  in  obstruction  by  tumor,  usually  to  be  felt  as  a  large  and 
elastic  distended  tumor  under  the  right  ribs. 

4.  To  the  enlargement  of  the  spleen.  In  obstruction  of  the 
choledochus  by  stone  the  spleen  is  said  to  be  frequently  enlarged, 
whilst  by  tumor  it  is  wanting. 

5.  To  ascites.  In  case  of  benign  stone-disease  it  is  not  found  ; 
in  malignant  cancerous  disease  it  frequently  occurs. 

6.  To  fever.  In  obstruction  of  the  common  duct  by  stone, 
fever  is  frequently  present ;  in  obstruction  by  tumor  it  is  usually 
wanting ;  yet  it  occurs  in  exceptional  cases,  especially  in  the  last 
stages  of  the  disease. 

7.  To  the  duration  of  the  disease.  Patients  with  cancer  of 
pancreas,  duodenum  or  choledochus,  are  usually  ill  only  a  few 
months,  at  most,  a  year,  whilst  patients  with  lithogenous  obstruc- 
tion of  the  choledochus  often  have  to  suffer  for  years.  I  have 
operated  upon  a  patient  who  was  ill  12  long  years  with  symp- 
toms of  chronic  lithogenous  choledochus  obstruction.  She  re- 
covered completely. 

8.  To  the  previous  history  of  the  case.  Previous  colics  speak, 
if  jaundice  occurs,  more  for  obstruction  of  the  choledochus  by  a 
stone  than  by  a  tumor  ;  yet  it  is  not  so  very  rare  that  a  chronic 
obstruction  of  the  choledochus  is  the  first  alarming  symptom 
of  a  cholelithiasis  until  then  latent. 

9.  To  the  cachexia.  It  is  usually  more  pronounced  in  carci- 
noma than  in  stone,  yet  stone  patients,  to  which  I  have  already 
often  referred,  may  be  so  ill, — especially  under  the  influence  of 
fever,  etc., — that  they  acquire  the  entire  appearance  of  cancer 
patients.  Leichtenstern  calls  attention,  moreover,  to  the  im- 
portance of  Virchow's  gland  in  the  differentiation  of  cancerous 
from  lithoorenous  obstruction  of  the  common  duct  : 


92  GALLSTONE  DISEASE. 

"  On  the  other  hand  there  is  another  by  no  means  rare  sign 
of  great  value  for  the  diagnosis  of  cancer,  a  sign  which  for  me 
has  been  an  especially  valuable  guide-post  in  a  large  series  of 
often  difficult  differential  diagnoses  of  diagnosis  of  lung,  bronchial, 
pleural  and  oesophageal  cancer,  far  more  rarely  in  cancer 
of  stomach.  It  is  the  swelling  of  the  jugular  glands,  occasioned 
b>'  cancerous  infiltration, — Virchow's  gland,  that  lymph  gland 
which  lies  behind  the  clavicular  attachment  of  the  sterno-cleido- 
mastoid,  often  extending  at  the  side  over  the  latter,  and  which 
may  swell  to  the  size  of  cherries,  chestnuts,  in  rarer  cases  to  the 
size  of  a  hen's  egg.  In  a  large  series  of  difficult  differentiations, 
whether  cancer  of  gall-bladder  or  simple  cholelithiasis,  whether 
calculous  or  cancerous  obstruction  of  the  choledochus,  whether 
cancer  of  liver  or  cirrhosis,  the  '  Virchow  gland  '  has  shown  itself 
to  me  an  eminently  important  and  never  deceitful  guide." 

I  can  confirm  the  observations  of  Leichtenstern  ;  but  one  finds 
the  gland  only  in  advanced  cases,  and  in  these  the  correct  diag- 
nosis is  usually  not  difficult,  since  we  have  at  our  disposal  a  series 
of  other  landmarks.  Finally,  permit  me  still  a  few  remarks  con- 
cerning the  landmarks,  which  admit  of  a  distinction  between 
dropsy  and  empyema  of  the  gall-bladder  and  cancer  of  the  gall- 
bladder. In  the  beginning  of  the  cancer  development  the  cor- 
rect diagnosis  is  not  easy,  since,  in  our  experience,  the  cancer 
formation  goes  on  stealthily,  without  the  patient  observing  any- 
thing of  his  horrible  disease.  Although  we  surely  know  that  gall- 
stones furnish  the  excitant  for  the  formation  of  cancer,  the  majority 
of  men  who  later  suffer  from  cancer  of  the  gall-bladder  complain  in 
general  of  no  trouble  which  indicates  the  presence  of  gallstones. 
And  it  is  indeed  the  perversity,  the  insidiousness,  and  the  malig- 
nancy of  the  disease  that  it  is  exactly  there  where  it  occasions 
the  greatest  dangers,  by  the  development  of  cancer,  by  perfora- 
tions into  the  belly,  by  the  occurrence  of  gallstone-ileus  that  it 
runs  so  notoriously  without  symptoms.  I  have  seen  cases  of 
ileus  in  which  hens'  egg-sized  stones  were  jammed  in  the  lower 
end  of  the  ileum  and  nothincr  had  hinted  at  cholelithiasis.     I  have 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  93 

seen  men  in  most  glowing  health  die  suddenly  as  if  by  lightning 
stroke  from  an  acute  perforation  peritonitis,  and  none  had  a  sus- 
picion of  gallstones.  And  then,  when  the  necropsy  explained  the 
cause,  the  relatives  have  given  the  assurance  that  the  deceased  had 
indeed,  now  and  then,  occasionally  complained  of  slight  stomach 
troubles,  but  never  of  colic-like  pains.  And  I  have  treated 
patients  with  cancer  of  gall-bladder  who  have  never  been 
plagued  a  single  instant  by  gallstone  troubles.  In  fact,  if  the 
disease  with  open  vizor  had  challenged  us,  its  opponents,  the 
doctors,  to  a  contest,  we  would,  indeed,  already  have  grown  to 
it,  and  have  soon  driven  it  from  the  field.  But  so  malignantly 
to  make  ravages  behind  one's  back  which  no  one  divines,  and 
on  this  account  no  one  can  prevent,  is  a  baseness  which  often 
enough  has  exasperated  me.  If,  later,  the  disease  shows  itself  in 
its  true  form,  it  has  then  so  widely  extended  itself  that  we  must, 
as  powerless,  lay  down  our  arms.  This  is  exactly  the  case  with 
carcinoma  of  the  gall-bladder.  When  this  occasions  its  first  dis- 
comfort and  irregularities  are  to  be  felt  on  the  gall-bladder,  then 
we  usually  come  too  late  with  our  art.  At  all  events,  a  tumor 
of  the  gall-bladder,  if  it  develops  beyond  the  50th  year  and  as- 
tonishes by  its  hardness,  is  suspicious  and  ought  to  arouse  the 
suspicion  of  carcinoma.  If  to  this  is  added  disturbance  of  the 
appetite,  and  constant,  even  though  not  lively,  pains,  then  one 
should  urge  operation.  Is  jaundice  for  the  first  time  present, 
then  it  is  a  proof  that  the  carcinoma  has  extended  to  the  bile 
ducts  ;  if  ascites  and  cachexia  occur,  then  operative  procedures 
have  absolutely  no  purpose.  The  diagnosis,  as  difficult  as  it  may 
be,  must  be  made  early  ;  and  exactly  with  those  patients  whose 
parents  and  brothers  and  sisters  have  died  of  cancer  ought  one 
in  active  cholelithiasis  to  advise  the  prompt  removal  of  the  stone, 
in  order  to  prevent  the  development  of  carcinoma.  In  such 
cases,  as  I  have  already  explained  above,  I  operate  even  when 
I  find  a  tumor  of  the  gall-bladder  which  up  till  then  has  not 
given  rise  to  the  slightest  discomfort. 

We  have  heretofore  learned  to  recognize  those  cases  in  which 


94 


GALLSTONE  DISEASE. 


I 


a  diagnosis  was  relatively  easy  to  make.  But  often  a  correct 
diagnosis  is  rendered  very  difficult.  A  fistula  between  gall- 
bladder and  stomach  may,  for  example,  develop  entirely  without 
symptoms,  and  only  in  rare  cases  will  we  be  able  to  diagnosti- 
cate "  fistula  of  the  gall-bladder  and  stomach."  But  in  most 
instances  we  will  make  the  diagnosis  not  before  or  during  the 
formation  of  the  fistula,  but  first,  as  a  rule,  after  it.  This  is — inci- 
dentally remarked — also  quite  well,  for  in  general  it  is  wrong  to 
disturb  the  procedures  of  a  natural  cure.  If  stones  are  vomited, 
then  one  may  not  yet  say  that  they  have  reached  the  stomach 
through  an  unnatural  fistula.  Just  as  easily  as  bile  flows  back- 
ward through  the  pylorus,  even  as  easily  can  small  stones  come 
into  the  stomach  and  be  vomited.  In  case  of  the  vomiting  of  a 
large  stone,  the  suspicion  of  a  fistula  between  gall-bladder  and 
stomach  is  justified. 

The  diagnosis  of  external  fistulse  is  easier.  If  in  the  region  of 
the  gall-bladder  the  abdominal  wall  becomes  oedematous  and 
suppuration  develops,  after  the  incision  of  which  a  fistula  results 
which  continually  secretes  mucus,  then  one  is  obliged,  even 
when  no  colics  have  preceded,  to  suspect  that  the  inflammatory 
process  is  to  be  ascribed  to  the  gall-bladder.  More  difficult, 
indeed,  will  the  diagnosis  be  if  a  rupture  occurs  at  the  navel  or 
at  Poupart's  ligament.  By  careful  probing  we  are  usually  in 
position  to  recognize  cholelithiasis  as  the  original  disease.  The 
diagnosis  will  be  absolutely  certain  if  bile  is  excreted  or  stones 
come  to  appearance.  Biliary-lung  fistulae  are  easy  to  diagnose 
if  the  patients  expectorate  bile-colored  sputum,  or  even  gall- 
stones. 

In  a  great  number  of  cases,  however,  a  special  diagnosis  is  in 
general  no  longer  possible.  If  abnormal  communications  have 
formed  between  gall-bladder  and  intestine,  so  that  the  bile  can 
flow  from  the  hepatic  duct  through  the  cystic  duct  and  thence 
into  the  intestine,  then  the  choledochus  may  be  completely 
plugged  toward  the  duodenum  without  our  being  in  position  to 
diagnosticate  this  obstruction  of  the  choledochus.    We  may  guess 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  95 

it,  if  from  time  to  time  the  patient  becomes  yellow,  with  it  has 
fever  and  chills,  if  the  liver  alters  its  volume  ;  to  make  a  correct 
diagnosis,  will  be  possible  for  no  one.  No  wonder  if,  in  such 
cases,  the  decision  for  operation  will  be  difficult  for  physician  and 
patient,  since,  as  a  rule,  the  colics  are  not  typical  ;  for  the  bile 
can  pass  off  through  the  abnormal  communications  and  the 
tension  in  the  bile  ducts  is  not  very  great  ;  jaundice  and  colics 
remain  absent.  For  such  cases  an  exact  amnesis  and  the  pur- 
suit of  the  gallstone  disease  from  year  to  year  is  again,  for  the 
possibility  of  a  diagnosis,  a  better  guide  than  the  results  of  exam- 
ination. In  case  also  of  participation  of  the  pylorus  in  the 
inflammatory  processes  of  the  gall-bladder  and  its  surroundings, 
so  long  as  the  pylorus  is  patent  a  correct  diagnosis  is  not  always 
possible.  On  the  other  hand,  one  diagnosticates  solely  a  stenosis 
of  the  pylorus  and  thinks  not  at  all  of  gallstones,  despite  the 
cause  of  the  trouble  is  to  be  ascribed  only  to  these.  A  classical 
example  of  this  kind  is  represented  by  the  first  gallstone  opera- 
tion which  I  have  done.  I  hold  the  case  in  such  thankful 
remembrance  for  this  reason,  that  it  laid  the  foundation  for 
later  undreamed-of  successes,  and  for  the  great  collection  of 
gallstone  operations  to  which,  up  to  the  present  time,  no  other  sur- 
geon has  attained.  Until  then,  at  the  University  and  during  my 
time  as  assistant,  I  had  never  seen  a  gallstone  operation.  After 
the  successful  operation  which  I  performed  upon  the  patient, 
the  interest  of  Halberstadt  and  its  surroundings  in  gallstone 
surgery  was  awakened  ;  the  case  brought  me  new  ones,  which 
likewise  recovered  ;  it  impelled  me  to  numerous  publications 
concerning  the  surgical  treatment  of  cholelithiasis  ;  there  came 
constantly  more  patients  from  the  nearer  and  distant  environs  of 
Halberstadt,  and  now  gallstone  surgery  has  become  a  specialty 
in  my  clinic.  There  are  not  wanting  cancers  of  the  breast  and 
tuberculosis  of  the  joints  ;  of  other  surgical  diseases  I  see  enough, 
yet  cholelithiasis  forms  the  leading  contingent  of  my  operations. 
Of  the  600  patients  whom  I  treat  yearly  in  my  clinic,  80  to  100 
suffer  from   gallstones.      On   this   account   I   always   think   with 


96  GALLSTONE  DISEASE. 

affection  of  the  poor  seamstress,  whose  sorrowful  appearance  on 
entering  my  house  I  will  never  more  forget.  Hollow-eyed,  with 
prominent  cheek-bones,  of  the  age  of  27  years,  with  a  weight  of 
80  pounds,  she  showed  me  a  tumor  of  the  right  hypochondrium 
which  all  doctors  up  till  then  had  regarded  as  a  carcinoma. 
Without  any  doubt  there  was  also  a  tumor  of  the  pylorus,  for  the 
distension  of  the  stomach  showed  distinctly  how  the  larger  and 
smaller  curvatures  ran  directly  into  the  tumor.  Moreover,  the 
stomach  was  dilated  to  the  maximum  ;  the  patient  had  vomiting, 
but  no  real  colic.  Who  at  that  time,  ten  years  ago,  knew  anything, 
indeed,  of  gall-bladders  which  could  become  so  adherent  to  the 
pylorus  that  they  completely  compressed  it  ?  Yet  this  tumor 
masqueraded  as  the  hypertrophied  pylorus  rather  than  a  gall- 
bladder full  of  stones  and  adherent,  and  my  operation  at  that 
time,  cystendesis,  after  removal  of  the  stones,  and  Loreta's  opera- 
tion, again  restored  the  patient  to  life.  She  regained  her  strength 
and  recovered  completely,  and  on  every  twenty-second  of  May, 
the  day  of  her  operation,  she  appears  with  touching  fidelity  to 
express  her  thankfulness. 

Almost  \yithout  symptoms  had  it  come  in  this  case  to  adhe- 
sion of  the  gall-bladder  to  the  pylorus.  At  all  events  there 
were  no  real  colics.  Now^  I  would,  perhaps,  make  the  correct 
diagnosis,  but  at  that  time  I  knew,  of  the  A,  B,  C  of  gallstone 
disease,  scarcely  the  A,  and  opened  the  abdomen  in  the  firm 
conviction  of  finding  a  cancer.  With  increasing  experience  I 
learned  to  recognize  that  adhesions  between  gall-bladder  and 
pylorus  after  cholecystitis  are  by  no  means  so  rare  as  one  had 
formerly  thought.  Since  gallstone  patients  frequently  become 
very  ill  with  disturbances  of  the  stomach,  the  doctor  must  be 
well  trained  in  all  the  methods  of  examination  which  come  into 
use  in  stomach  diseases,  and  the  surgeon  especially  has  rea- 
son to  occupy  himself  with  examinations  of  the  stomach's  con- 
tents, etc.,  since  upon  their  data  the  question  of  operative  treat- 
ment will  frequently  depend. 

From    the    above    explanations    you    observe   that   a   special 


THE  SPECIAL  DIAGNOSIS  OF  CHOLELITHIASIS.  97 

diagnosis  is  possible  in  many  cases  of  cholelithiasis,  in  many 
very  difficult  and  many  entirely  impossible.  To  the  last  cate- 
gory belongs  also  the  intrahepatic  cholelithiasis,  which  long 
years  may  be  latent,  to  suddenly  appear  under  symptoms  of 
diffuse  cholangitis  (painfulness  in  the  whole  liv^er  region,  fever, 
jaundice,  etc.)  as  a  very  severe  disease. 

I  will  close  my  lecture  of  to-day  with  the  hint  that  the 
classification  of  cholelithiasis  used  until  now  is  entirely  insuffi- 
cient, and  does  not  correspond  to  the  actual  conditions.  Thus, 
for  example,  Naunyn  distinguishes  between  a  regular  and  an 
irregular  form.  By  the  regular  form  he  understands  the  long- 
known  gallstone  colic,  the  acute  obstruction  of  the  choledochus. 
Under  the  irregular  he  reckons  cholecystitis,  dropsy,  empyema 
of  the  gall-bladder  and  chronic  obstruction  of  the  coledochus. 
The  regular  form  of  Naunyn  is,  however,  relatively  rare  ;  an 
acute  obstruction  of  the  choledochus,  with  passage  of  the  stone, 
also  can  develop  after  a  sero-purulent  cholecystitis;  then  the 
regular  form  is  first  a  consequence  of  the  irregular.  From  this 
it  indeed  proceeds  that  this  classification  should  be  rejected, 
and  I  have  the  conviction  that  Naunyn  will  not  retain  it  in  a 
second  edition  of  his  classical  work.  To  me  it  seems  most 
fitting  if  we  make  the  foundation  of  the  classification  of  chole- 
lithiasis the  degree  of  inflammation,  the  seat  of  the  stone  ;  in  a 
word,  the  pathologico-anatomical  condition.  I  am  myself  very 
well  aware  that  it  is  not  always  easy,  indeed  in  many  cases  impos- 
sible, without  opening  the  abdomen,  to  make  a  pathologico-ana- 
tomical diagnosis,  yet  it  is  possible  in  most  cases,  and  whoever 
proceeds  according  to  my  classification  will  in  the  future  be  able 
to  make  the  following  diagnoses  : 

1.  Gallstones  in  gall-bladder,  with  patent  cystic  duct. 

2.  Gallstones  in  gall-bladder,  with  obstructed  cystic  duct. 

(A)  Acute  form  of  cholecystitis, 
(a)  serous  cholecystitis. 
(/S)  purulent  cholecystitis. 


98  GALLSTONE  DISEASE. 

(B)  Chronic  form. 

(a)  dropsy,  and 

(/^)  empyema  of  gall-bladder. 

3.  Gallstones  in  the  cystic  duct. 

(a)  acute  obstruction. 

(b)  chronic  obstruction. 

4.  Pericholecystitis  (adhesions). 

5.  Carcinoma  of  gall-bladder. 

6.  Carcinoma  of  head  of  the  pancreas,  choledochus  and  duo- 
denum. 

7.  Cholangitis  diffusa,  thrombophlebitis,  etc. 

The  diagnosis  of  mixed  forms — for  example,  of  empyema  of 
the  gall-bladder  with  synchronous  chronic  obstruction  of  the 
choledochus — is  very  difficult,  and  ought  only  exceptionally  to 
succeed.  In  such  cases  one  will  only  succeed  in  diagnosticating 
the  ;/iost  prominent  form  of  gallstone  disease. 

Riedel  distinguishes  between  gallstone  disease  with  and  with- 
out jaundice.  This  division  is  to  be  rejected.  The  chief  repre- 
sentative of  cholelithiasis  with  jaundice  is  the  chronic  obstruc- 
tion of  the  choledochus  by  stone;  but  how  frequently  jaundice  is 
wanting,  how  often  is  one  obliged  to  make  the  diagnosis  chronic 
obstruction  of  the  choledochus  ev^en  without  jaundice,  solely  by 
reason  of  the  amnesis,  from  the  character  of  the  fever,  from  the 
appearance  of  colics,  and  from  the  appearance  of  the  patient, 
etc.  I  believe  on  this  account  that  it  is  in  fact  best  to  employ 
henceforth  the  classification  given  by  me  above.  In  so  doing 
we  will  not  forget  that  a  considerable  series  of  very  difficult,  and 
on  this  account  so  much  the  more  important,  pathological 
changes  in  the  bile  canals  will  remain  closed  to  our  knowledge  ; 
even  then  when  we  have  still  further  improved  the  special  diag- 
nosis of  gallstone  disease.  The  more,  however,  we  endeavor  to  • 
make  special  diagnoses  in  gallstone  disease,  so  much  the  easier 
will  we  succeed  in  settling  the  question  of  the  treatment  of  gall- 
stone disease,  which  we  will  make  the  subject  of  our  next 
lecture. 


LECTURE  IV. 
THE  TREATMENT  OF  CHOLELITHIASIS. 

Gentlemen  :  Although  I  from  the  beginning  had  the  inten- 
tion ofoccLipying  myself  in  these  lectures  only  with  the  diagnostic 
questions,  yet  I  believe  I  would  still  do  a  service  to  the  prac- 
titioner if,  in  conclusion,  I  give  in  large  outlines  my  views  re- 
garding the  treatment  of  cholelithiasis. 

Gallstone  disease  is,  as  we  all  know,  an  extraordinarily  fre- 
quent disease  ;  every  tenth  adult  man  carries  about  with  him  the 
concretions,  but  of  the  two  millions  of  Germans  who  have  gall- 
stones, only  100,000  complain  of  their  trouble  ;  with  the  remain- 
der the  disease  is  in  a  latent  condition.  Latent  cholelithiasis  is 
now  to  be  regarded,  on  the  whole,  as  a  rather  harmless  affection, 
but  in  so  doing  we  should  not  forget  that  cancer  of  the  gall- 
bladder may  develop  from  the  irritation  of  the  stones  actually 
lying  quiescent  in  its  fundus.  Yet  it  is  so  relatively  rare,  that  the 
principle,  quiet  lying  stones  are  no  subjeets  for  treatment,  enjoys 
a  general  acceptation  with  the  internists  and  the  surgeons. 

We  physicians  first,  if  inflammatory  processes  which  arise  in 
the  gall-bladder  put  the  stones  in  motion,  have  occasion  to 
proceed  against  the  tormentors.  It  is  not  my  intention  to 
give  you  special  directions  concerning  the  use  of  morphine,  of 
hot  poultices,  or,  indeed,  of  proving  the  efficiency  of  Durand's 
mixture,  the  chologogues,  and  of  olive  oil.  All  are  agreed,  and 
this  Naunyn  especially  emphasizes,  that  we  should  think  less  of 
the  treatment  of  the  attack  of  colic  and  much  more  of  the  relief 
of  the  disease  itself.  In  fact,  only  by  two  methods  of  treatment 
can  the  troubles  of  the  gallstone  patients  be  assuaged  and  cured 
— either  by  a  Carlsbad  cure  or  by  an  operation. 

99 


lOO  GALLSTONE  DISEASE. 

Simplest  of  all  would  it  be  if  we  possessed  a  means  which 
would  dissolve  the  stones  in  the  gall-bladder.  We  all  know 
that  we  unfortunately  know  of  none  such,  and  no  physician 
thinks  that  the  hot  Sprudel  of  Carlsbad  possesses  any  such  won- 
derful power,  although  the  cure-guests,  tarrying  there,  in  a  re- 
markable manner,  still  believe  it.  With  the  solution  of  the 
stones,  the  sequelae,  inflammation,  strictures,  perforations,  etc., 
are  far  from  being  cured  ;  and  so  internal  medicine  will  fail  in  a 
certain  number  of  cases,  even  if  a  solvent  for  the  concretions 
should  be  discovered.  Still  in  another  way  has  internal  medi- 
cine sought  to  bring  gallstone  disease  to  a  cure.  For  a  long 
time  they  have  endeavored  to  drive  the  stones  from  the  gall- 
bladder through  the  cystic  and  common  ducts  into  the  intes- 
tine. They  employed  the  so-called  chologogues  :  in  so  doing 
they  remained  in  doubt  whether  the  stones,  on  account  of  their 
size,  were  in  general  adapted  to  the  passage  through  the  narrow 
ducts.  If  they  are  too  large  they  remain  sticking  in  the  cystic 
duct,  and  then  one  has  done  more  harm  than  good.  If  the 
stones  are  small,  then  the  contractions  of  the  gall-bladder  mus- 
cle may  sometimes  succeed  in  expelling  the  stones  entirely.  In 
general,  I  believe  that  we  doctors  are  hardly  in  position  by  any 
sort  of  a  medicament  to  accomplish  the  expulsion  of  the  stones 
from  the  gall-bladder. 

With  stones  in  the  common  duct  it  may,  indeed,  sooner  suc- 
ceed. In  this  case  one  may  employ  chologogues,  unfortunately 
often  without  any  sort  of  success.  To  the  assistance  of  our 
medical  powerlessness,  however,  Nature  comes  often  enough  ; 
she  succeeds,  especially  when  she  excites  inflammatory  processes 
in  the  gall-bladder,  in  exciting  small  stones  to  pass,  but  even 
large  stones  she  expels  when  she  unites  the  gall-bladder  with  the 
hollow  organs  of  the  abdomen  by  abnormal  openings  and  lets 
the  concretions  pass  by  such  a  route.  But  in  this  also  we  never 
know  whether  a  complete  cure  is  attained  ;  however,  we  are  con- 
tent if  the  patient  no  longer  has  distress  and  his  disease  has 
passed   into  the   latent  stage.      For  a  persistent  latent  stage  is 


THE  TREATMENT  OF  CHOLELITFITASIS.  lOI 

almost  as  good  as  a  cure.  The  proof  of  this  assertion  is  the  fact 
that  thousands  upon  thousands  of  men  in  the  German  Empire 
have  not  the  sHghtest  distress  from  their  gallstones.  If  we 
possess  no  means  of  forcing  stones,  especially  the  large  ones, 
through  the  duct  into  the  intestine,  we  must  regard  as  the  chief 
aim  of  internal  medicine  to  bring  about  the  stage  of  latency, 
and  I  personally  have  the  impression  that  the  majority  of  patients 
at  Carlsbad  lose  their  pains,  not  that  they  are  relieved  of  all  their 
stones,  but  since  the  inflammatory  processes  only,  which  first 
make  known  the  gallstone  disease,  are  relieved.  In  an  earlier 
lecture  I  said,  concerning  this,  what  follows  : 

"  By  the  use  especially  of  the  hot  springs,  the  condition  of  the 
circulation  in  the  liver  and  the  portal  system  in  general  in  the 
abdomen  are  improved  ;  catarrhs  of  the  stomach  and  intestine — 
inflammatory  processes  which  extend  from  duodenum  to  chole- 
dochus,  from  the  gall-bladder  to  the  bile  duct — are  quickly  re- 
lieved ;  and  since  the  majority  of  colics,  at  least  according  to  my 
humble  judgment,  are  of  inflammatory  origin,  so  indeed  can, 
after  a  few  beakers  of  Sprudel,  the  colic  pain  cease.  The  gall- 
stone disease  passes  into  the  stage  of  latency,  in  which  are, 
according  to  Riedel,  about  95  per  cent,  of  gallstone  cases. 
Kocher  himself  says  that  in  his  own  gallstone  attacks,  after  a  few 
weeks  the  hot  Sprudel,  during  the  colics,  had  attained  the  relief 
of  his  suffering,  nota  bene,  without  the  stones  being  expelled. 
And  the  majority  of  Carlsbad  physicians  with  whom  I  have 
spoken  are  completely  convinced  of  the  cramp-  and  pain-allaying 
action  of  the  hot  Sprudel.  '  It  acts  as  a  hot  poultice  or  as 
opium.  One  needs,  in  fact,  during  the  season,  scarcely  once  to 
use  the  hypodermatic  syringe.'  " 

Certainly  this  wonderful  action  is  present,  for  one  often  hears 
at  the  springs  the  patients  declare,  "  I  am  free  from  my  pains, 
but  the  stones  have  not  been  expelled."  One  can,  however, 
only  explain  this  occurrence  in  this  way.  The  inflammation 
ceases,  and  the  usually  large  stone  lying  in  the  neck  of  the  gall- 
bladder again   becomes  free,  so  that  the  bile  can  then   flow  un- 


I02  GALLSTONE  DISEASE. 

hindered  in  and  out.  Thus  the  patient  beheves  himself  cured  ; 
we,  as  physicians,  know  that  he  has  been  freed  from  his  coHc, 
his  inflammation,  his  obstruction,  but  not  from  his  disease. 

On  the  one  hand,  experience  teaches  also  that  in  a  series  of 
cases  one  or  two  colics  remain  ;  yet,  on  the  other  hand,  it  is  even 
as  certain  that  the  majority  of  patients  are  always  again  attacked 
by  inflammations.  For  where  once  an  inflammation  has  found 
a  suitable  soil,  there  it  causes  a  locus  minoris  resistenti^  which 
it  always  attacks  by  preference. 

Since  the  internal  practitioner  usually  was  powerless  against 
these  constantly  recurring  attacks,  the  surgery  of  gallstone  dis- 
ease has  increased  in  the  last  fifteen  years  and  attained  out  and 
out  brilliant  results. 

In  the  beginning,  one  regarded  himself  only  justified  in  an 
operation  if  all  baleneological,  hygienic  and  medicinal  means 
had  proven  themselves  of  no  avail.  They  regarded  operation  as 
the  ultimum  refugium  ;  they  operated  only  from  a  vital  indication  ; 
then  came  a  time  when  one  could  not  resort  too  early  to  the 
knife,  because  the  numerous  operations  offered  the  demonstra- 
tion that  the  removal  of  stones  from  well  accessible  gall-bladders 
was  relatively  easy  and  entirely  without  danger,  whilst  the  ex- 
traction of  concretions  from  the  bile  ducts,  the  cysticus  and 
choledochus,  always  exacted  their  tribute,  and  to-day  most  sur- 
geons subscribe  to  the  doctrine  that  one  should  govern  his  action 
according  to  the  special  form  of  the  disease.  I  have  from  the 
first  taken  this  stand,  and  have  always  been  of  the  opinion  that 
certain  cases — I  recall  only  the  acute  sero-purulent  cholecystitis 
— belong  without  question  to  the  surgical  clinic,  whilst  again 
others — I  have  in  mind  especially  the  cases  of  jaundice  and  ex- 
pulsion of  stones — can  find  in  the  hot  Sprudel  relief  from  their 
suffering,  and  perhaps  also  complete  cure. 

If  von  Winiwarter  says  that  with  the  diagnosis  "gallstones"  the 
indication  is  also  given  for  operation,  then  he  goes  too  far ;  and 
if  Kraus,  of  Carlsbad,  would  permit  surgical  intervention  only 
upon  a  vital   indication,  so  is    he   also  wrong.      By  the   middle 


THE  TREATMENT  OE  CHOLELITHIASIS.  IO3 

path  we  best  reach  our  end,  and  we  ought  never  "  to  attempt  an 
operation  without  weighing  well  what  will  be  the  reward  and 
purpose  of  the  hazard."  For  every  laparotomy  can  bring 
danger ;  I  remind  you  of  the  occurrence  of  pneumonia,  the  for- 
mation of  hernia,  and  that  even  anaesthesia  may  occasion  severe 
ill  health.  On  the  other  hand,  the  practitioner  is  sometimes  in- 
clined to  let  the  pathological  changes  extend  so  far  that  neces- 
sity drives  him  and  the  patient,  with  unconquerable  force,  to 
operation  ;  he  thinks  only  of  the  dangers  of  operation  ;  forgets 
that  dawdling  frequently  is  much  more  dangerous  than  a  lapa- 
rotomy and  anaesthesia.  Whoever  is  the  operator,  indeed  who- 
ever assists  him  and  looks  after  the  anaesthetization  in  the  general 
employment  of  surgical  procedures  in  cholelithiasis,  comes  very 
much  under  consideration.  The  operation,  which  for  the  one  is 
very  easy,  is  for  the  other  very  difficult. 

Thus,  for  instance,  the  mortality  of  the  choledochotomy  varies 
from  10-30  per  cent.  At  all  events  the  surgical  knife  plays  at 
present,  in  the  therapeutics  of  cholelithiasis,  a  very  great  role,  and 
obtains  immediately  brilliant  results  ;  thus,  among  my  patients 
who  had  their  gallstones  only  in  the  gall-bladder,  the  mortality 
does  not  yet  exceed  i  per  cent.  The  mortality  after  total 
extirpation  amounts  to  3  per  cent.,  and  after  choledochotomy  to 
about  10  per  cent.  My  experience  includes  about  100  cystec- 
tomies and  60  choledochotomies  ;  the  remaining  operations  were 
cystostomies,  cystocotomies,  etc.  Bad  is  the  prognosis  when 
the  gallstone  disease  is  complicated  with  cancer,  thoroughly  bad 
when  septic  and  pyaemic  conditions  develop.  Who  can  blame 
me,  if  I  advise  the  patient  to  be  operated  upon  so  long  as  the 
stones  are  still  in  the  gall-bladder  ?  It  must  be  my  duty,  in  view 
of  my  success,  to  operate  early  so  long  as  the  cholelithiasis  is 
confined  to  the  gall-bladder,  and  it  would  be  unscientific  of  me 
if  I  did  not  mention  the  great  dangers  of  cholelithiasis  and  the 
relative  freedom  from  danger  of  an  early  operation.  That, 
moreover,  constantly  more  confidence  is  placed  in  gallstone  sur- 
gery is  proven  for  me  by  the  circumstance  that  I  already  have 
freed  8  colleagues  from  their  gallstones. 


I04  gallstonp:  disease.  j 

With  some  satisfaction  I  note  the  fact  that  exactly  in  the  past 
year  the  labors  of  the  surgeons  in  the  treatment  of  gallstone 
disease  have  obtained  a  long  deserved  appreciation  from  the  side 
of  the  internists.  Especially  has  Naunyn,  at  the  last  Naturalists' 
meeting  in  Diisseldorf,  reported  his  experience  concerning  the 
treatment  of  cholelithiasis.  As  much  as  I  rejoice  over  the 
friendly  reception  which  this  most  distinguished  internal  clinician 
extended  to  the  surgeons  on  that  day,  yet  I  cannot  agree  with 
him  yet  fully  on  the  following  point:  "  Before  operation  can  be 
generally  recommended  to  patients  as  the  only  sure  means  to 
cure  gallstone  disease,  it  must  first  be  determined  how  far  it 
actually  guarantees  certain  cure."  This  demand  of  Naunyn 
seems  to  me  to  have  little  excuse,  for  it  is  unknown  to  me  that 
a  surgeon  has  ever  declared  operation  to  be  an  absolutely  cer- 
tain means  of  making  impossible  a  future  formation  of  stones.  * 
We  surgeons  can  as  yet  do  do  nothing  further  than  to  remove 
all  the  stones  which  are  present,  and  so  regulate  the  conditions 
of  the  biliary  system  that  a  possible  recurrence  will  be  avoided. 
The  tendency  to  the  formation  of  stones  neither  the  internal 
practitioner  nor  the  surgeon  can  prevent ;  not  even  if  we  in  all 
cases  remove  the  gall-bladder,  open  up  extensively  the  chole- 
dochus,  and  drain  the  hepaticus.  It  is  unfair  to  expect  of  a  sur- 
geon that  in  all  cases  he  will  attain  ideal  results.  Possible  is  it 
only  in  the  early  stages  of  the  disease,  when  the  stones  are  not 
yet  in  the  cysticus,  and  on  this  account  the  blame  that  we  sur- 
geons cannot  always  remove  all  stones  belongs  less  to  us  than 
to  the  internal  colleagues,  who  usually  only  advise  operation 
when  the  concretions  have  left  their  original  abiding-place  and 
have  become  lodged  in  the  cysticus  and  choledochus.  It  does 
not  at  all  occur  to  us  surgeons  to  require  of  a  Carlsbad  cure 
a  complete  restitutio  ad  integrum  ;  therefore  it  is  just  and 
proper  that  the  internal  practitioner,  in  the  demands  which  he 
makes  of  the  surgeons,  does  not  go  excessively  far.  We  must 
furthermore  remember  that  we  still  stand  on  the  threshold  of 
gallstone  surgery  ;  the  more  an  operator  has  delved  in  his  field. 


THE  TREATMENT  OF  CHOLELITHIASIS.  IO5 

SO  much  the  better  will  he  succeed  in  removing  all  stones.  The 
beginner  overlooks  many  a  stone  in  the  choledochus  and  cys- 
ticus,  and  on  this  account  recurrences  are  not  to  be  charged  to 
the  account  of  surgery  in  general,  but  rather  to  the  not  suffi- 
ciently experienced  operator  concerned.  I  now  lay  not  only 
the  gall-bladder  free,  but  also  the  cysticus  and  choledochus,  and 
do  not  shy  at  introducing  my  finger  into  the  hepatic  and  com- 
mon ducts  to  guard  against  leaving  stones  behind.  In  fact,  I 
have  in  recent  time  overlooked  no  more  stones,  not  even  if  they 
in  quantity  stuck  in  the  cholodochus.  But  if  we  have  to  deal 
with  stones  in  the  gall-bladder  only^  then  no  sto)ies  ought  to 
remain  behvid. 

The  troubles  which  declare  themselves  in  rare  cases  after  suc- 
cessful operations  are  to  be  ascribed  usually  to  adhesions,  the 
fixation  of  the  gall-bladder  to  the  abdominal  wall,  etc.,  and  not  to 
stones  left  behind  or  again  developing.  As  disagreeable  as  these 
adhesion-disturbances  can  be,  they  still  bring  no  actual  danger 
with  them.  And  that  is  still  the  principal  point.  For  we  take  up 
the  knife  to  prevent  the  great  dangers  of  cholelithiasis,  suppura- 
tion, jaundice,  carcinoma,  perforation,  cirrhosis  of  the  liver,  and 
we  can  give  the  patient,  if  he  again  feels  pain,  the  assurance  that 
there  can  be  no  question  of  danger  to  his  life.  Naturally,  it  is 
necessary  that  in  so  doing  we  should  be  positive  that  we  have 
left  behind  no  stones.  Whoever  operates  at  two  sittings,  does 
the  ideal  operation  or  its  modification  by  Kiimmel,  locks  up  the 
choledochus,  and  will  never  be  able  to  entirely  satisfy  the  require- 
ments of  Naunyn.  On  the  choice  of  method  of  operation,  on  the 
technique,  practice  and  experience  of  the  surgeon,  will  it  depend 
whether  we  hereafter  are  obliged  to  have  the  reproach  come  to 
us  that  stones  are  overlooked.  When  I  formerly  buried  silk 
sutures  which  attached  the  gall-bladder  to  the  abdominal  wall, 
I  observed  in  three  cases  true  colics.  The  silk  sutures  had 
dropped  into  the  gall-bladder  and  led  to  renewed  stone  for- 
mation. Since  then  I  have  left  the  silk  sutures  long,  and 
remove  them  in  toto.  The  possibility  that  after  a  successful 
9 


I06  GALLSTONE  DISEASE. 

Operation  distress  should  again  occur,  because  of  adhesive  pro- 
cesses, is  greater  in  cystostomy  than  in  cystectomy.  In  the 
retained  organ  cholecystitis  can  again  occur.  On  this  account 
I  have  recently  given  the  preference  to  excision  of  the  gall- 
bladder. If  gallstone  surgery  develops  in  the  next  century  as 
in  the  last  years  of  the  century  drawing  to  a  close,  then  I  have 
no  doubt  that  we  surgeons  will  attain  results  w^hich  our  thankful 
cotemporaries  will  view  with  amazement. 

Not  only  will  we  strive  for  the  immediate  relief  of  pain,  but,  so 
far  as  it  in  general  lies  in  the  power  of  man,  for  a  pcntianciit 
cure  in  the  true  sense  of  the  word.  This  hope  will  then  first  be 
fulfilled  when  internal  medicine  and  surgery  write  on  their  banner 
the  device,  "  Viribus  unitis,"  and  when,  united,  they  take  the  field 
against  the  obstinate  foe.  The  chief  command  in  this  w^ar  we 
will  gladly  leave  to  internal  medicine,  if  we  have  the  assurance 
that  the  counseling  voice  of  surgery  is  not  neglected.  Before  I 
pass  to  answering  the  two  questions 

1.  What  gallstone  cases  shall  we  send  to  Carlsbad?  and 

2.  When  shall  we  operate  ? 

I  believe  I  ought  to  make  clear  to  you  in  a  few  words  the  con- 
cept Early  Operation. 

I  understand  by  early  operation  the  surgical  attack,  at  a  time 
in  which  the  stones  are  still  in  the  gall-bladder  and  the  patholog- 
ical changes  in  it  have  not  advanced  too  far  about  it.  I  have 
always  laid  emphasis  on  this,  that  one  should  remove  the  stones 
before  they  perforate  the  gall-bladder  or  get  into  the  deep  ducts ; 
we  only  thus  can  avoid  numerous  cystectomies  and  choledo- 
chotomies.  These  operations  will  not  be  entirely  thrust  out  of 
the  world,  since  cholelithiasis  often  remains  for  years  latent,  to 
suddenly  cause  an  obstruction  of  the  choledochus,  which  finally 
requires  a  choledochotomy.  This  very  difficult  operation  may 
even  also  be  a  true  early  operation,  while  one  may,  on  the  other 
hand,  even  in  cases  in  which  the  gallstones  have  already  laid 
decades  in  the  gall-bladder,  succeed  with  a  simple  cystostomy  ; 
and  yet  this  is  no  longer  an  early  operation.      From  this  it  ap- 


I 


THE  TREATMENT  (JE  CHOLELITHIASIS.  lO/ 

pears  that  the  conception  of  an  early  operation  is  very  difficult 
to  define,  and  upon  its  further  retention  I  no  longer  lay  any  great 
value.  Nevertheless,  whoever  knows  what  unexpected  difficul- 
ties the  removal  of  an  ulcerated  gall-bladder  or  the  extraction  of 
stones  from  the  choledochus  occasions,  will  agree  with  me  that 
all  our  endeavors  must  be  directed  either  to  bring  the  stones  to 
quiescence  in  order  that  their  presence  should  be  limited  to  their 
original  home,  the  gall-bladder,  or,  on  the  other  hand,  to  remove 
them  before  they  cause  all  the  evil  sequelae,  such  as  suppuration, 
chronic  jaundice  and  cancer  formation,  cirrhosis  of  the  liver, 
fistula  formation  and  gallstone  ileus.  The  slight  dangers  of  early 
operation  stand  in  no  sort  of  a  relation  with  the  great  dangers  of 
the  disease  itself.  This  conviction  ought  more  and  more  to  gain 
strength,  and  not  only  in  medical  circles,  but  even  in  the  lay 
public  gain  a  firm  footing.  It  is  very  lamentable  that  the  scien- 
tific practitioner  has  scarcely  any  opportunity  of  influencing  the 
wider  circles  of  the  people,  for  just  as  soon  as  he  opens  his  mouth 
in  any  sort  of  a  society  not  a  medical  one  he  is  exposed — often, 
indeed,  with  reason — to  the  charge  of  advertising.  The  natural 
doctor  and  the  empiric,  however,  scatter  the  poison  of  their 
teaching  ever  further,  and  we  are  obliged  to  connive  at  stupidity 
and  folly  gaining  always  more  and  more.  Thus,  also,  the  dan- 
gers of  cholelithiasis  are  far  too  little  known  among  the  people  ; 
it  passes  as  a  harmless  disease,  although  only  in  the  period  of 
latency  can  there  be  any  question  of  it.  Even  the  latent  chole- 
lithiasis we  should  always  regard  with  suspicious  eyes,  for  the 
''quiet  work"  of  gallstones  is  often  the  most  destructive. 
Carcinoma  often  arises  through  stones  which  cause  no  distress, 
and  perforations  into  the  hollow  organs  develop  not  rarely 
without  any  symptoms.  No  one  should  trust  latency  too  much  ; 
in  malignancy  and  insidiousness  no  disease  of  man  compares  with 
cholelithiasis. 

Even  in  Carlsbad  they  are  scarcely  convinced  of  the  danger  of 
gallstone  disease,  perhaps  for  the  reason  that  most  frequently 
only  the   milder  cases  come  there  under  observation.      At   least 


I08  GALLSTONE  DISEASE. 

this  follows  from  a  work  of  Hermann,  a  Carlsbad  physician,  who 
assumes  that  the  vast  majority  of  the  gallstone  patients  treated 
in  Carlsbad  belong  to  the  regular  form  of  cholelithiasis.  Under 
the  regular  form  Naunyn  comprises,  briefly  said,  the  acute  ob- 
struction of  the  choledochus  with  passage  of  stones.  If  I  also 
admit  that  the  Carlsbad  colleague  is  better  informed  concerning 
the  cure-guests,  who  there  seek  cure,  than  I  who  tarried  only 
four  weeks  long  in  the  renowned  cure  resort  and  was  obliged  to 
make  my  observations  more  from  a  distance,  yet  as  a  surgeon 
must  I  still  declare  that  the  inflammatory  processes  in  the  gall- 
bladder, without  expulsion  of  stones,  occur  far  more  frequently 
than  acute  obstruction  of  the  choledochus  with  passage  of  the 
stone  through  the  papilla  of  the  duodenum.  But  even,  assum- 
ing that  Hermann's  view  as  to  the  relatively  greater  frequency 
of  the  regular  form  of  cholelithiasis  is  true,  yet  I  cannot  agree 
with  him  when  he  asserts  that  only  in  the  regular  form  do  the 
mineral  waters  bring  assistance,  whilst  in  the  irregular  forms 
they  show  themselves  unsuccessful.  Under  the  irregular  forms 
Naunyn  comprises 

1.  Stone  incarceration. 

2.  Chronic  gallstone  icterus. 

3.  The  infectious   diseases  of  the  bile  ducts  and  liver  abscess 

in  cholelithiasis. 

(a)  cholangitis. 

(b)  the  infectious  cholecystitis  and  empyema  of  the  gall- 

bladder (hydrops  cystidis  fellea;). 

(c)  infectious  hepatitis  (abscess  of  liver). 

4.  The  ulcerative  diseases  of  the  gall  ducts  and  fistula  forma- 
tion. 

5.  Diseases  of  the  intestine  caused  by  gallstones. 

6.  Diffuse  hepatitis. 

7.  Cancer  of  the  bile  ducts. 

In  most  of  these  forms  of  irregular  cholelithiasis  will  Carls- 
bad cure,  of  course,  show  itself  useless  ;  but  I  am  convinced 
that  in  this  and  that  case  of  stone  incarceration,  of  cholecystitis, 


THE  TREATMENT  OF  CHOLELITHIASIS.  IO9 

and  even  of  cholangitis,  the  hot  Sprudel  will  render  good  ser- 
vice, since  by  exciting  peristalsis,  and  improvement  in  the  circu- 
lation of  the  liver  and  portal  system,  it  actually  contributes  to  the 
relief  of  inflammatory  processes  in  the  bile  ducts.  At  all  events 
it  would  be  ill-suited  to  the  reputation  of  Carlsbad  if  benefit 
only  resulted  in  the  regular  form  ;  the  number  of  gallstone 
operations  would  of  necessity  immeasurably  increase  if  we 
based  our  indications  for  surgical  treatment  on  the  foundation  of 
Hermann's  views  regarding  the  action  of  the  Carlsbad  springs 
upon  the  different  forms  of  cholelithiasis.  If  we  followed  the 
conclusions  of  Hermann,  then  the  subject  would  be  very  sim- 
ple ;  the  regular  form  of  Naunyn,  the  acute  obstruction  of  the 
choledochus,  with  passage  of  stones,  belongs  to  Carlsbad  ;  all 
others,  the  irregular  form,  belong  to  the  surgical  clinic.  I  do 
not  believe  among  the  Carlsbad  physicians  there  are  many  who 
agree  with  Hermann,  and  I  myself,  as  a  surgeon  standing  far  on 
the  other  side,  must  refuse  any  such  wide  extension  of  the  indi- 
cations. We  surgeons  ought  actually  to  rejoice  at  a  response 
of  that  kind,  but  I  regard  it  as  still  more  proper  if  we  remain 
right  objective  and  do  not  press  our  claims  in  regard  to  opera- 
tiv^e  procedures  in  gallstone  disease  too  far.  Despite  I  am  ac- 
customed as  an  operator  to  treat  always  only  the  severer  forms 
of  cholelithiasis,  by  which  fact  the  pessimistic  view  of  the  prog- 
nosis of  gallstone  disease  is  explained,  I  am  heartily  inclined 
to  acquit  of  the  belief  the  internists  who  make  the  prognosis 
much  more  favorable  than  we  surgeons,  since  they  see  so  many 
cases  which  run  their  course  favorably  and  smoothly.  Never- 
theless, Fiirbringer  declares  cholelithiasis  to  be  a  grave  disease  ; 
to  the  same  view  comes  Naunyn,  who  says  of  it  what  follows  : 

"  Cholelithiasis  is  a  disease  which  becomes  dangerous  through 
cholecystitis  and  cholangitis  and  their  consequences,  through 
chronic  icterus,  and  through  carcinoma. 

"  It  exhiVjits  itself  now  also  really  as  avery  grave  disease  in  many 
forms.  I  have  treated  in  the  Strassburg  Medical  Clinic  alone 
some  250  cases  of  gallstone  disease,  of  150  of  which  sufficiently 


no  GALLSTONE  DISEASE. 

accurate  clinical  histories  are  in  my  hands.  Of  these  150,  20 
died  ;  7  died  in  consequence  of  cholecystitis  and  cholangitis, 
fistula  formation,  perforations  into  the  belly,  abscess  of  the  liver, 
etc.  Eleven  died  of  carcinoma  of  the  bile  ducts,  and  to  these 
belong  3  cases  which  left  the  institution  before  death  with  ap- 
parently indubitable  cancer. 

"That  is  in  all  14  cases  of  carcinoma  in  cholelithiasis.  Of 
chronic  jaundice  without  carcinoma,  two  died.  That  the  dan- 
ger of  all  these  fatal  complications  increases  with  the  duration 
of  the  disease  is  shown  by  the  fact  that  almost  all  the  fatal  cases 
occurred  in  old  people  with  old  gallstone  disease  ;  only  2  deaths 
occurred  among  people  under  50  years  ;  in  both  there  existed 
cholelithiasis  with  carcinoma. 

''  Of  the  I  50  cases  60  are  cured. 

'*  Yet  in  many  of  chese  cases  discharged  as  cured  there  has, 
indeed,  been  no  real  cure.  Some  went  out  as  cured,  still  with 
slight  sensitiveness  and  enlargement  of  the  liver,  and  even  in 
apparently  completely  cured  cases  occasionally  recurrences  took 
place  after  a  few  Aveeks. 

"It  is  not  to  be  wondered  at  that  in  the  clinical  material  chole- 
lithiasis so  readily  shows  its  bad  side,  for  the  cases  with  mild 
first  attacks  of  cholelithiasis  rarely  enter  the  clinic. 

"  In  the  private  practice  cholelithiasis  presents  without  question 
a  very  gratifying  picture.  There  are  cases  enough  which,  after 
one  or  a  few  attacks,  remain  permanently  cured,  free  for  ever  or 
at  least  for  decades  ;  in  these  cases  we  have  in  general  never 
anything  to  do  with  the  evil  life-threatening  consequences  of 
cholelithiasis. 

"  But  the  clinical  material  teaches  the  one  thing  as  private  prac- 
tice teaches  it  in  the  same  definite  manner  :  among  the  *  cured  ' 
are  not  so  few  who  already  have  borne  their  disease  long  years  ! 
And  yet,  gentlemen,  even  if  I  endeavor  ever  so  earnestly  to  be 
completely  objective,  I  cannot  by  reason  of  that  which  my  private 
practice  teaches  free  myself  from  the  conviction  that  cholelithiasis 
is  a  disease  which,  in   far  the   greatest  majority  of  cases,  runs  a 


THE  TREATMENT  OF  CHOLELITHIASIS.  I  I  I 

favorable  course  even  without  surgical  interference.  A  harmless 
disease  it  certainly  is  not,  because  cholecystitis  and  cholangitis 
threaten  with  grave  consequences,  and  in  the  future  stalks  the  ap- 
parition of  cancer."  I  quote  intentionally  the  views  of  Naunyn 
to  show  that  I  do  not  dogmatically  hold  my  vieivs  for  the  only 
correct  ones.  That  I  do  not  think  favorably  of  the  prognosis  of 
cholelithiasis  is  also  to  be  seen  from  a  previous  lecture,  which 
went  as  follows  :  "  Why  should  one  always  operate  immedi- 
ately ?"  says  the  Carlsbad  physician  ;  "  the  disease  is  not  eit  all  so 
dangerous.  I  see  hundreds  of  gallstone  patients  come  with 
colics  and  depart  without  pain,  and  although  they  every  year 
return,  they  lead  a  very  desirable  life.  Besides  the  suppurative 
processes,  carcinoma,  perforations  are  so  rare  that  I  can  by  no 
means  make  the  prognosis  of  the  disease  so  grave  as  the  sur- 
geons love  to  do."  On  the  other  hand  says  the  operator  who 
has  worked  much  in  this  field  :  **  In  my  opinion  cholelithiasis  is 
an  obstinate  malignant  disease  which  at  any  moment  may  take  a 
bad  turn  and  lead  to  death.  And  since  I  possess  in  the  cystos- 
tomy  a  means  to  easily  and  without  danger  prevent  these  evil 
results,  I  then  appeal  to  this  means  at  the  proper  time,  that  is, 
early,  before  severe  complications  exist." 

Whence  is  this  contradiction  in  view^s  of  the  representatives  of 
the  two  great  branches  of  the  healing  art  ? 

First  of  all  I  will  admit  that,  from  his  own  standpoint,  each 
is  right ;  the  Carlsbad  physician  just  as  much  as  the  surgeon — 
that  one  first  recognizes,  if  he  has  been  in  Carlsbad  and  has  scru- 
tinized the  gallstone  material  there.  If  one  jumbled  the  two  views 
together  and  made  an  abstract  of  them,  then  in  so  doing  there 
should  result  the  correct  view  concerning  the  medicinal  or  sur- 
gical treatment  of  cholelithiasis.  One  understands,  if  one  person- 
ally discusses  it  with  the  Carlsbad  physicians,  very  well  their  reserve 
toward  gallstone  surgery,  and  comes  to  the  conclusion  that  ac- 
tually the  difference  in  the  opposing  views  is  not  by  any  means  so 
much  a  matter  of  principle  as  one  in  the  beginning  is  inclined  to  as- 
sume.    In  fact  I  could,  with  different  Carlsbad  colleagues  who  had 


112  GALLSTONE  DISEASE. 

a  great  experience,  come  very  soon  to  an  agreement  concerning 
the  aims  of  the  choleUthiasis  treatment,  and  quickly  would  we  be 
in  accord  on  this,  that  it  solely  on  the  material,  which  is  at  the 
command  of  the  surgeon  and  Carlsbad  physician,  depends  why 
the  surgeon  is  more  for  an  operative  and  the  Carlsbad  physician 
more  for  an  expectant  treatment.  Let  one  himself  only  once 
look  around  in  Carlsbad.  I  expected  to  find  at  the  springs  of 
Carlsbad  greenish-yellow  features,  filled  with  that  well-known 
pain  and  anxiety,  such  as  are  so  peculiar  to  cholelithiasis.  One 
must  actually  seek  to  discover  in  Carlsbad  a  severely  ill  gall- 
stone patient.  I  have  in  my  stay  of  four  weeks  been  able  only 
in  few  cases  to  make  the  diagnosis  of  chronic  lithogenous  ob- 
struction of  the  choledochus,  although,  of  course,  I  know  that 
there  are  cases  of  choledo-cholelithiasis  which  run  their  course 
entirely  without  jaundice,  and  although  I  must  admit  that  such 
a  facial  diagnosis  has  no  great  value.  It  may  also  be  that  some 
patients  with  chronic  obstruction  of  the  choledochus,  on  account 
of  fever,  etc.,  were  treated  in  their  lodgings  ;  but  patients  of  that 
sort,  as  I  know  from  experience,  the  Carlsbad  physician  sends 
back  to  their  home  with  the  direction  to  have  an  operation.  Far 
too  often  one  sees  patients  who  apparently  suffer  from  cancer  of 
the  stomach,  of  the  liver  and  of  the  intestine.  If  they  are  no 
longer  operable,  that  which  is  almost  always  sure  to  be  the  case, 
then  there  is  no  reason  to  oppose  a  stay  in  Carlsbad.  They  are 
sent  to  Carlsbad  only  **  solaminis  causa,"  and  "  ut  aliquid  fiat ;" 
they  visit  also  the  springs  willingly,  since  they  know  that  this  or 
that  stomach  sufferer  has  been  cured  in  Carlsbad.  The  gall- 
stone patients  without  jaundice  are,  of  course,  far  more  numer- 
ous. Almost  all  belong  to  the  well-to-do  class,  the  poor  dis- 
appear absolutely.  The  patients  come  to  Carlsbad  usually  in 
the  period  of  latency  ;  the  minority  still  have  colics  or  inflam 
mation  of  the  gall-bladder.  Now  begins  the  regular  living,  the 
beneficial,  pain-assuaging,  laxative  action  of  the  Carlsbad  springs, 
the  delightful  influence  of  the  Sprudel  baths  with  their  peat 
poultices  to  the  liver  and  region  of  the  gall-bladder.      The  beau- 


THE  TREATMENT  OF  CHOLELITHIASIS.  II3 

tiful  surroundings  entice  the  cure-guest  into  the  noble  forest,  he 
cHmbs  the  mountains,  which  in  stillness  leave  nothing  to  wish 
for,  and  he  forgets  the  worry  of  his  business  and  the  pain  of  his 
disease.  The  cuisine  permitted  b)'  the  cure  removes  the  sins  of 
his  club  life  at  home,  of  the  many  strawberry  and  peach  punches  ; 
briefly,  the  tissue  changes  are  powerfull)'  stimulated,  and  who- 
ever is  not  very  sick  must  in  a  very  short  time  indeed  feci  him- 
self well.  Of  course,  moreover,  the  principal  material  of  the 
Carlsbad  doctors  is  not  the  chronic  obstruction  of  the  choledo- 
chus,  but  the  gall-bladder  lithiasis  of  the  prosperous  class. 
Therein  is  the  explanation  also  of  the  opinion  of  Kraus  that  the 
disease  occurs  more  commonly  among  the  rich  than  among  the 
poor  ;  an  opinion  which,  according  to  my  experience,  is  surely 
not  the  correct  one.  I  beg  pardon  if  I  have  been  somewhat 
prolix  concerning  the  prognosis  of  cholelithiasis,  for  the  de- 
scription of  the  treatment  of  it,  however,  appeared  to  me  to  be 
absolutely  necessary.  I  believe  that  the  framing  of  indications 
for  the  internal  or  surgical  treatment  as  I  have  given  them  in  ni)- 
lecture  of  September  i,  1898,  will  find  the  acceptance  of  all 
physicians  who  are  accustomed  to  govern  their  action  by  reason 
of  the  pathological  processes  occurring  in  gallstone  disease.  I 
can  repeat  to-day  what  I  then  said  at  the  conclusion  of  my  lec- 
ture. We  treat  not  the  disease,  but  the  sick  men,  and  in  the 
question  whether  we  operate  or  treat  medicinally,  whether  we 
content  ourselves  with  the  relief  of  pain  or  strive  to  bring  about 
an  actual  cure,  the  age,  the  sex  and  the  social  position  of  the 
patient  plays  a  mighty  role.  On  patients  who  have  passed  their 
sixtieth  year  I  only  then  operate  when  a  vital  indication  is  present 
(empyema  of  the  gall-bladder,  chronic  choledochus  obstruction)  ; 
I  operate  more  willingly  upon  women  than  men,  mothers  more 
willingly  than  maidens.  The  reasons  for  it  I  need  not  indeed 
explain.  The  poor  laborer's  wife  cannot  pursue  a  cure  at  Carls- 
bad ;  she  belong-.s,  if  she  can  no  long^er  direct  her  household,  if 
she  can  no  longer  fulfill  the  rearing  of  her  children,  to  a  surgical 
clinic.      For  the  laborer  with  wages  of  2  to  3  marks  a  day,  an  earl}^ 


114  GALLSTONE  DISEASE. 

dangerless  cystostomy  will  most  quickly  bring  about  the  neces- 
sary restoration  to  health.  Rich  people  who  can  spare  them- 
selves may  once  a  year  journey  to  Carlsbad  and  afterward  to 
the  sea  or  the  mountains,  may  with  slight  inflammatory  pro- 
cesses in  the  gall-bladder  and  seldom  recurring  attacks  of  colic 
pursue  an  internal  treatment  until  they  understand  that  they 
must  be  operated  upon.  The  woman  in  prosperous  circum- 
stances can  regulate  her  diet  according  to  the  treatment ;  the 
poor  cigarette  maker  is  limited  to  her  potatoes  and  fatty  food, 
and  will  not  so  easily  be  delivered  from  her  stomach  pains. 

At  the  conclusion  of  my  lecture  at  that  time  I  condensed  my 
views  thus  : 

I.  An  internal  treatment  or  a  Carlsbad  cure  I  recommend 
to  patients  : 

1.  with  acute  obstruction  of  the  choledochus,  so  long  as  it 
proceeds  normally  (if  it  drags  along,  if  fever  occurs,  if  accelera- 
tion of  the  pulse,  i(  cholangitic  symptoms  appear,  then  operation 
may  be  considered) ; 

2.  with  inflammatory  processes  in  the  gall-bladder,  with  and 
without  jaundice,  if  they  occur  rarely  and  not  too  violently.  In- 
deed, the  pain  does  not  always  correspond  to  the  severe  patho- 
logical changes  in  the  bile  system  and  in  the  abdomen,  so  that  the 
subjective  troubles  of  the  patients  ought  not  to  be  for  us  physi- 
cians decisive,  but  we  will  in  such  cases,  even  with  the  clear  data 
of  palpation,  not  always  succeed  in  our  recommendation  for 
operation,  since  the  patients  yield  themsehes  to  operation  only 
because  of  unendurable  distress  ; 

3.  with  frequent  colics  each  time  attended  with  the  passage  of 
stones. 

If  the  colics  recur  very  often  without  the  passage  of  stones, 
then  operation  is  indicated  ; 

4.  who  suffer  from  obesity,  gout,  diabetes,  or  in  whom  on 
account  of  affections  of  the  heart,  lungs,  kidneys  or  liver,#the 
dangers  of  anaesthesia  come  into  consideration  ; 

5.  who  have  undergone  operation.      I  have  already  repeatedly 


THE  TREATMENT  OF  CHOLELTTHTASIS.  1 1  5 

said  that  I  would  most  gladly  send  every  gallstone  case  which 
had  undergone  operation  to  Carlsbad.  Unfortunately  I  rarely 
accomplish  it.  The  joy  of  returning  home  is  so  great  that  an 
after-treatment  in  Carlsbad  is  scorned.  The  patient  usually  does 
not  comprehend  that  now  in  spite  of  operation  there  is  still  place 
for  a  Carlsbad  cure,  and  comes  often  to  the  opinion  that  the 
operation  has  not  been  thoroughly  enough  done.  Usually,  how- 
ever, there  is  wanting  to  the  operative  cases,  who  belong  for  the 
most  part  to  the  working  classes,  the  necessary  gulden  and 
kreutzers  (dollars  and  cents). 

If  the  stones  are  in  the  choledochus,  then  the  cholagogues 
(olive-oil,  glycerine,  salicylate  of  soda,  bile  acids)  may  be  em- 
ployed ;  if  the  stones  still  lie  in  the  gall-bladder,  if  we  do  not 
wish  or  ought  not  to  operate,  it  must  be  then  our  endeavor  to 
set  aside  the  inflammation  and  to  bring  about  rest,  but  not  to 
shake  up  the  stones  and  expel  them  by  cholagogues.  '*  To 
bring  about  rest,"  that  is  the  solution  of  the  internal  medication 
in  gall-bladder  stones,  and  a  Carlsbad  cure  seems  to  me  in  every 
way  suitable  to  meet  this  requirement. 

At  all  events  it  appears  to  me  that  the  aim  of  the  internal 
physician  to  expel  the  stones  through  the  narrow  ducts  into  the 
intestine  is  more  dangerous  than  the  endeavor  of  the  surgeon 
to  remove  the  stones  through  the  abdominal  walls.  By  reason 
of  my  experience  I  cannot  rid  myself  of  this  opinion. 

II.   Under  all  circumstances  must  incur  operation  : 

1.  the  acute  sero-purulent  cholecystitis   and  pericholecystitis  ; 

2.  the  adhesions  between  gall-bladder  and  intestine,  stomach  ; 
omentum  resulting  from  the  latter,  assuming  that  they  cause 
distress  (pains,  peripyloritis,  pylorostenosis,  stenosis  of  the 
duodenum,  ileus,  etc.)  ; 

3.  chronic  obstruction  of  the  choledochus  ; 

4.  chronic  cysticus  obstruction  (dropsy,  empyema  of  the  gall- 
bladder) ; 

5.  all  those  forms  of  cholelithiasis  begin  as  light  attacks,  but 
in  their  further  course,  despite  every  balneological  and  medicinal 


ii6  GALLSTONE  DISEASE. 

treatment  and  by  persistent  distress  (pains  in  the  stomach,  ema- 
ciation) embitter  for  the  patients  the  enjoyment  of  Hfe,  and  make 
impossible  the  exercise  of  their  profession  ; 

6.  purulent  cholangitis  and  abscess  of  the  liver ; 

7.  perforation  processes  in  the  bile  ducts  and  peritonitis  ; 

8.  gallstone  morphinism.  Here  the  operation  is  the  best 
beginning  of  a  successful  withdrawal  treatment ;  in  my  clinic  I 
have  saved  many  a  morphine-taker  from  certain  death. 

For  the  confirmation  of  these  views  I  add  the  following : 
The  acute  obstruction  of  the  choledochus  may  lead  to  the 
cure  of  the  gallstone  disease,  if  at  one  time  or  in  different  attacks 
there  results  the  expulsion  of  the  stones  into  the  intestine.  To 
wait  for  this  cure  of  nature  would  be  wrong.  On  the  other 
hand,  it  must  be  our  duty  to  assist  it.  At  all  events,  there  is  no 
reason  for  operating  in  such  a  case,  and  I  have  often  enough 
treated  expectantly  cases  of  that  kind  which  had  been  sent  to 
me  for  operation.  The  interested  colleagues,  who  had  sent  the 
patients  to  me,  were  very  much  astonished  regarding  my  cautious- 
ness, and  could  not  at  all  comprehend  that  I,  who  do  not  long 
hesitate  with  the  knife,  should  refuse  a  bloody  interference.  It 
always  concerned  patients  with  whom  the  symptoms  of  gall- 
bladder inflamttnation  were  relatively  but  little  pronounced,  whilst 
the  appearance  of  jaundice  showed  that  the  stone  had  already 
left  the  gall-bladder  and  moved  into  the  choledochus  in  its  wan- 
dering toward  the  intestine.  Here  may  one  quietly  wait, 
whether  the  passage  of  the  stone  through  the  papilla  does  not 
yet  succeed,  and  although  I  well  know  that  it  v^ery  seldom  suc- 
ceeds in  a  single  colic,  yet  I  cannot  blame  such  patients  if  they 
decline  an  operation,  since  they  feel  themselves  at  the  moment 
free  from  pain. 

The  patient  has  suffered  day  in  and  out  the  most  horrible 
tortures  ;  since  now  the  appetite  and  the  bodily  strength  re- 
turns, the  jaundice  disappears  and  the  stone  was  found  in  the 
stool,  ought  he  then  to  expose  himself  to  the  terrors  of  anaes- 
thesia and  the  pain  of  a  laparotomy  ?  That  is  in  fact  to  ask 
too  much. 


THE  TREATMENT  OF  CHOLELITHIASIS.  II7 

Entirely  different  is  the  question  if  the  gall-bladder  in  spite 
of  the  expulsion  of  the  stone  remains  sensitive  and  is  to  be  felt 
as  a  tumor,  or  if  the  stone  is  not  expelled  and  the  symptoms  of 
cholangitis  (intermittent  fever,  chills,  marked  jaundice,  enlarge- 
ment of  the  liver,  great  painfulness  of  the  capsule  of  the  liver) 
appear,  if  the  disease  is  prolonged,  if  loss  of  appetite  and  loss  of 
strength  develop.  There  may  occur  in  such  cases,  from  time  to 
time,  once  in  a  while  a  cure  under  the  expectant  treatment,  or  the 
cholelithiasis  may  become  latent,  yet  the  dangers  of  the  expec- 
tant treatment  are  certainly  greater  than  those  of  the  surgical. 
And  if  we  have  the  choice  of  two  evils,  then  let  us  choose  the 
less,  which  is  in  this  case  operation.  Easy  and  without  danger  it 
is  not,  for  we  must  open  the  choledochus,  and,  on  account  of 
the  existing  cholangitis,  we  must  not  close  it,  but  ought  to 
drain  the  hepaticus  and  conduct  the  infectious  bile  outside.  I, 
as  the  first,  brought  this  operation  one  and  a  half  years  ago  into 
use,  and  am  with  its  results  very  content,  and  I  am  very  glad 
that  Quincke,  from  the  standpoint  of  an  internal  clinician,  desig- 
nates the  drainage  of  the  hepaticus  as  a  rational  procedure. 
Among  the  surgeons,  also,  the  procedure  has  found  acceptance, 
as  is  to  be  seen  from  the  contributions  of  Lobker,  Poppert  and 
Petersen. 

The  acute  obstruction  of  the  choledochus,  as  is  to  be  seen 
from  my  explanations  concerning  the  pathological  anatomy  of 
gallstone  disease,  is  usually  first  the  consequence  of  an  inflam- 
mation of  the  gall-bladder.  It  proceeds  immediately  from  this, 
that  it  would  be  wrong  to  treat  by  operation  every  inflammation 
of  the  gall-bladder,  since  we  otherwise  prevent  the  possibility 
of  a  spontaneous  cure.  Only  such  cases  of  inflammation  of  the 
gall-bladder  as  despite  a  Carlsbad  cure  do  not  abate,  as  always 
again  occur  anew,  and  in  which  the  expulsion  of  the  stone  fails, 
demand  an  operation.  We  have  seen  above  that  the  inflamma- 
tory processes  in  the  gall-bladder,  when  the  infection  is  slight 
and  is  soon  extinguished,  need  not  come  to  the  knowledge  of 
the  patient,  and   may  pass   so   quickly   that  a  distension  of  the 


I  1 8  GALLSTONE  DLSEASE. 

gall-bladder  does  not  occur.  Since  palpation  data  are  wanting 
and  the  pains  do  not  long  persist,  neither  the  physician  nor  the 
patient  can  decide  upon  operation.  I  also,  of  course,  in  quickly 
passing  inflammations  of  that  sort  have  scarcely  ever  operated, 
since  a  surgical  clinic  is  always  regarded  as  the  last  refuge  which 
one  seeks,  when  the  pains  increase  and  internal  treatment  fails. 
First  when  the  inflammation  in  threatening  manner  advances, 
the  physician  clearly  feels  the  gall-bladder,  and  the  pains  tor- 
ture unceasingly  the  patient,  comes  into  consideration  the  ques- 
tion of  operation.  I  take  the  position  that  the  acute  sero-puru- 
lent  cholecystitis  must  under  all  circumstances  be  operated 
upon  as  soon  as  a  tumor  of  the  gall-bladder  is  discovered.  If 
it  is  not  the  case,  as  in  the  case  of  high-lying  or  already  con- 
tracted gall-bladders,  then  one  must  make  the  necessity  of  the 
operation  dependent  upon  the  pains,  the  general  condition  of  the 
patient,  and  by  no  means,  least  of  all,  on  the  skill  and  ability  of 
the  particular  operator.  The  opening  of  a  deep-lying  gall- 
bladder is  no  work  of  art,  but  to  so  make  the  incision  that  one 
does  not  provoke  a  peritonitis  is  a  great  piece  of  skill.  In  the 
hands  of  the  aseptically  trained  and  experienced  surgeon  the  oper- 
ation in  the  deep-lying,  inflamed  gall-bladder  is  less  dangerous 
than  the  expectant  treatment ;  exactly  the  opposite  is  the  fact  if 
a  beginner  in  surgery  or  a  physician  not  specially  trained  under- 
takes the  operation.  Each  one  can  draw  for  himself  from  this 
assertion  the  necessary  deduction.  My  views  concerning  the 
treatment  of  cholecystitis  pretty  well  agree  with  those  of 
Naunyn.  On  some  points  we  disagree.  It  is  worth  while  to 
seek  for  the  reasons  which  occasion  these  differences.  Naunyn 
says  : 

"  In  the  whole  field  of  cholelithiasis  there  is  no  symptom  com- 
plex which  invites  more  to  operative  procedures  than  the  cases 
of  acute  cholecystitis  with  broad  prominent  tumor  of  the  gall- 
bladder ;  more  than  six  years  ago  I  have  already  declared  that 
one  ought,  as  a  matter  of  principle,  have  these  cases  operated 
upon,  for  on  the   one   hand  we   have  to  do   in  all  such  cases 


THE  TREATMENT  OF  CHOLELITHIASIS.  I  I9 

with  an  infectious  disease,  of  which  the  result  remains  always 
uncertain,  and  on  the  other  hand  the  cystostomy  is  in  no  case 
easier  to  execute.  Yet  one  ought  to  be  clear  concerning  the 
following  :  Should  the  determination  to  operate  be  arrived  at, 
then  it  must  be  often  quickly  performed,  for  even  with  violent 
cholecystitis,  with  immense  tumor  of  the  gall-bladder,  a  retro- 
gression can  quickly  occur,  so  that  the  gall-bladder  quickly  be- 
comes painless  and  smaller,  and  in  a  few  days  completely  escapes 
palpation.  Of  course,  under  these  circumstances  not  only  the 
patient,  but  also  the  surgeon,  who  has  not  previously  seen  the 
patient,  will  no  longer  decide  for  operation.  True,  it  has  hap- 
pened to  me  to  have  sent  into  the  surgical  clinic  such  patients, 
young,  strong  people,  without  fever  and  without  icterus,  with 
tumor  of  the  gall-bladder  ;  there  they  remained  in  bed  for  two 
days  for  observation  ;  then  the  gall-bladder  vanished  without  a 
trace,  and  after  a  few  days  longer  the  patients  were  discharged 
from  the  surgical  clinic  witJiotit  operation  as  cured. 

"■  One  will  not  always  in  such  cases,  if  one  advises  immediate 
operation,  avoid  the  reproach  of  excessive  zeal. 

*'  Whoever  proceeds  with  foresight  will  rather  wait  some  time, 
and  he  will  then  see  his  cases  for  the  most  part  recover  without 
operation  !  At  this  point  the  cases  of  cholecystitis-cholangitis 
acutissima,  with  violent  local  symptoms  of  irritation,  high  fever, 
severe  general  infection,  often  very  large  splenic  tumor,  deserve 
a  brief  description.  These  cases  may  die  very  quickly  from 
peritonitis,  even  without  perforation  of  the  walls  of  the  gall- 
bladder, as  Potain  has  seen,  and  by  general  infection,  as  I  have 
myself  seen.  One  ought  also  in  these  cases  operate  forthwith, 
yet  I  believe  the  surgeons  will  not  easily  come  to  this  determin- 
ation, perhaps  on  account  of  the  severe  general  suffering  and  on 
account  of  apprehension  of  the  infection  of  the  peritoneum  by  the 
very  infectious  contents  of  the  gall-bladder  in  such  cases.  It 
would  be  to  me  of  the  greatest  value  to  learn  the  opinion  of  our 
surgical  colleagues  concerning  this  point. 

"That  the  chronic  cholecystitis,  with  dropsy  of  the  gall-bladder, 
belongs  to  the  surgeons,  I  regard  as  decided." 


I20  GALLSTONE  DISEASE. 

I  have  to  these  explanations  of  Naunyn  to  note  the  following  : 
The  disappearance  of  the  tumor  of  the  gall-bladder  in  acute 
cholecystitis  I  have  observed  with  extraordinary  frequency,  and 
I  believe  him  absolutely  right  in  this  condition.  But  he  is 
scarcely  right  in  saying  "Whoever  proceeds  always  with  fore- 
sight will  rather  wait  some  time,  and  he  will  then  see  his  cases 
for  the  most  part  recover  without  operation."  I  am  far  rather 
of  the  opinion  that  the  physician  who  proceeds  with  foresight  in 
all  things  ought,  under  all  circumstances,  have  an  operation. 
Even  though  with  internal  treatment  of  lOO  cases  90  run  a 
smooth  course,  yet  with  surgical  treatment,  at  least  if  I  take  my 
own  experience,  there  are  99  positively  cured.  And  if  the  ope- 
ration saves  9  per  cent,  more  of  human  lives,  then  it  is  under  all 
circumstances  to  be  preferred  to  the  expectant  treatment.  At 
the  same  time  we  ought  not  to  forget  that  with  the  internal  treat- 
ment we  have  to  do  not  at  all  with  a  cure,  that  is  a  removal  of 
the  gallstones,  but  rather  with  a  silencing  of  the  inflammatory  pro- 
cesses by  which  the  stones  remain  quiescent.  The  operation,  on 
the  contrary,  removes  not  only  the  inflammation,  but  also  the 
stones,  by  a  cystostomy,  relatively  free  from  danger.  Its  mortality 
amounts  in  such  cases  in  which  the  gall-bladder  can  easily  be 
sewed  into  the  wound  scarcely  to  i  per  cent.  And  if  others 
have  shown  a  greater  percentage  of  mortality,  then  the  internal 
physicians  are  right  if  they  refrain  from  recommending  opera- 
tion, but  in  so  doing  they  should  not  forget  that  gallstone  sur- 
gery has  not  yet  become  the  common  property  of  all  operators, 
and  that  bad  results  in  cholecystitis  are  not  to  be  placed  to  the 
account  of  surgery  in  general,  but  to  that  of  the  individual 
surgeons. 

It  is  not  every  one  who  has  the  training  and  experience  which 
is  necessary  for  the  execution  of  gallstone  operations,  and  in  each 
specialty  there  are  beginners  who  must  first  very  gradually  ac- 
quire the  necessary  knowledge.  If  a  man  like  Kocher  can  show 
among  600  goiter  operations  only  one  death,  then  he  is  at  all 
events  justified   in   his  assertion  that  this    operation  is  without 


THE  TREATMENT  OF  CHOLELITHIASIS.  121 

danger.  And  if  I  in  eibout  i8o  cystostomies  saw  only  a  single 
fatal  result  in  consequence  of  the  operation,  then  one  will  agree 
with  me,  if  I  am  of  the  opinion,  that  in  the  hands  of  a  skilled 
aseptic  surgeon  such  an  operation  does  not  carry  with  it  note- 
worthy danger. 

At  all  events,  the  medical  treatment  of  acute  sero-purulent 
cholecystitis  conceals  in  itself  greater  dangers  than  the  operative 
treatment,  and  on  this  account  one  ought  to  completely  abstain 
from  the  former.  In  empyema  of  the  gall-bladder,  in  dropsy 
Naunyn  is  also  for  an  exclusively  surgical  treatment.  Of  course 
in  cases  of  cholecystitis-cholangitis  acutissima  we  instantly  appeal 
to  the  knife,  and  since  Naunyn  lays  great  stress,  upon  learning 
the  opinion  of  the  surgical  colleagues,  upon  this  point,  I  can 
report  to  him  that  I  have  operated  with  success  upon  a  series  of 
such  cases,  and  even  when  peritonitis  had  already  spread  widely. 

Before  we  proceed  further  we  will  in  a  few  words  condense 
the  results  up  to  this  time  of  our  observations. 

1 .  Unnecessary  is  operation  in  acute  obstruction  of  the  chole- 
dochus,  and  in  slight  inflammatory  processes  of  the  gall-bladder. 
With  these  we  usually  succeed  with  Carlsbad  cures. 

2.  Under  all  circumstances  an  operation  is  imperative  in  acute 
cholecystitis  with  clear  palpation  results.  If  these  are  wanting, 
but  general  appearances  and  separate  symptoms  are  those  of  an 
acute  inflammatory  process,  then  one  has  a  choice  between  a 
surgical  interference  and  waiting.  The  beginner  does  better  if 
he  does  not  operate,  since  the  opening  and  removal  of  a  deep- 
lying  pus-filled  gall-bladder  furnishes  great  difficulties  for  the 
experienced  gallstone  surgeon.  If  one  cannot  decide  upon  an 
operation,  then  one  should  at  least  recognize  that  the  patient 
during  an  expectant  treatment  is  always  exposed  to  great  dan- 
ger, and  should  never  refrain  from  explaining  this  in  clear  lan- 
guage to  the  patient.  Suppuration  foci  in  the  neighborhood  of 
the  gall-bladder  are  to  be  evacuated  as  soon  as  possible  accord- 
ing to  the  principle  :  Ubi  pus  ibi  evacua.  Indeed  I  well  know 
that  an   intraperitoneal  suppuration  can  become  encapsulated,  and 


122  GALLSTONE  DLSEASE. 

that  its  evacuation  at  a  later  period  may  be  technically  easier  and 
less  dangerous  than  earlier.  But  who  can  foresee  whether  the 
suppuration  becomes  encapsulated  or  whether  it  seizes  upon  a 
wider  territory  ?  At  all  events  the  practitioner  does  well,  on  the 
suspicion  of  pericholecystitis  exudativa,  to  call  to  his  assistance  a 
surgeon  who  has  had  the  necessary  experience.  Best  of  all,  the 
physician  should  send  the  patient  straightway  into  a  hospital  or 
into  a  clinic,  in  order  that  he  may  there  be  closely  watched  and  the 
proper  time  for  incision  not  be  let  slip.  If  the  fever  keeps  within 
moderate  limits,  if  the  pulse  remains  good  and  slow,  if  the  irrita- 
tion of  the  peritoneum  remains  limited  to  the  region  of  the  gall- 
bladder, then  one  may  wait  even  a  long  time.  With  this  ex- 
pectant method  the  patient,  of  course,  loses  his  courage  for  oper- 
ation and  becomes  undecided  since  the  inflammatory  symptoms, 
and  with  them  the  pains,  subside.  The  success  which  we  have 
attained  is  for  the  most  part  only  an  appearance  of  success  ;  the 
stones  remain  behind,  and  instead  of  the  exudate,  thickenings 
and  adhesions  occur,  which  on  their  part  may  give  rise  again  to 
severe  disturbances.  On  the  whole,  here  also  the  operative 
treatment  of  the  intraperitoneal  process  is  less  dangerous  than 
the  expectant  treatment.  Do  not  permit  yourselves,  gentlemen, 
by  the  few  spontaneous  cures  to  be  enticed  from  the  true  scien- 
tific path  ;  do  not  let  yourselves  be  bribed  by  the  exceptional 
cases  to  give  up  the  correct  treatment — and  it  for  all  suppura- 
tive processes  in  the  abdomen  is  operation. 

There  are,  indeed,  cases  of  perforative  peritonitis  known  in 
which  the  patients  recovered  even  without  surgical  interference, 
and  constantly  are  such  exceptions  again  cited  as  a  proof  that 
operation  is  not  indicated  under  all  circumstances.  Leichtenstern, 
for  example,  speaks  thus  : 

"  With  threatening  perforation,  which  appears  with  the  symp- 
toms of  a  sudden  severe  peritonitis  of  the  region  of  the  gall- 
bladder, one  should  follow  the  principles  of  the  treatment  of 
peritonitis.  Absolute  quiet,  ice-bag,  opium,  or  morphine,  little 
fluid  nourishment,  small   doses  of  iced  champagne,  restoratives. 


THE  TREATMENT  OF  CHOLELITHIASIS.  I  23 

The  decision  of  the  question  whether,  in  such  a  case,  an  opera- 
tion should  be  done,  belongs  to  the  most  difficult  which  there  is. 
Often  the  collapse  is  so  great  that  the  surgeon,  whom  I  imme- 
diately ask  in  consultation  in  all  these  cases,  declines  operation. 
So  also  in  a  case  observed  a  short  time  ago.  The  patient  re- 
covered completely.  If  the  collapse  again  disappears,  if  the 
symptoms  gradually  abate,  then  one  surely  is  not  inclined  to 
disturb  by  an  operative  interference  the  natural  cure  which  is 
progressing,  and  by  it  put  in  peril  its  most  favorable  termination. 

**  One  presents  the  subject  also  thus  :  Has  perforation  occurred, 
if  in  any  manner  still  a  rescue  is  possible,  then  this  is  only  to  be 
attained  by  a  laparotomy  ;  but  if  it  has  not  yet  resulted,  then 
the  operation  prevents  the  perforation  and  thus  saves  the  patient. 
The  alternative  pictured  thus  is  not  correct,  however.  The  oper- 
ation in  threatening  peritonitis  can,  apart  from  the  immediate 
danger  of  a  laparotomy  in  such  cases,  by  the  separation  of  fresh 
and  old  adhesions,  in  advancing  to  the  gall-bladder  easily  favor 
the  rise  of  a  fatal  general  peritonitis,  which  might  be  avoided  by 
quiet  waiting.  On  the  other  hand  I  will,  of  course,  not  deny  that 
in  one  or  the  other  case  the  subsequent  perforation  with  fatal  issue 
may  be  avoided  by  operation.  Occurrences  of  both  sorts  will 
never  be  put  out  of  the  world.  Our  treatment,  whether  expect- 
ant or  operative,  in  such  cases  from  the  absence  of  positive  indi- 
cations is  like  a  game  of  dice." 

Leichtenstern  in  many  respects  is  right.  I  have  also  not  the 
slightest  doubt  that  the  experienced  internal  clinician  has  been 
deceived  in  his  diagnosis  of  general  peritonitis,  although  he  will 
agree  with  me  that  an  entirely  circumscribed  peritonitis  capable 
of  cure  may  cause  oftentimes  exactly  the  same  stormy  symp- 
toms as  a  diffuse  purulent  peritonitis.  At  all  events  I  am  of  the 
firm  conviction  that  an  exceptionless  operative  treatment  of  per- 
forative peritonitis  gives  better  results  than  the  medical,  and  if  of 
100  patients  20  by  internal  treatment  are  saved  and  25  by 
operative,  then  is  the  latter  to  be  preferred  to  the  first.  I  have 
myself  by  operation  for  perforative  peritonitis  obtained  extra- 
ordinarily good  results. 


124  GALLSTONE  DLSEASE. 

Our  numerous  operations  upon  the  bile  system  have  resulted  in 
the,  at  the  beginning,  very  wonderful  and  startling  fact  that  gall- 
stone patients  could  still  have  the  most  violent  colic  pains  even 
after  all  stones  had  passed.  I  do  not  in  this  mean  those  cases  in 
which  the  cystic  duct  is  closed  by  a  scar  and  the  contents  of  the 
gall-bladder  have  turned  to  serum  or  pus.  I  have  rather  in 
mind  those  gall-bladders  of  which  the  cystic  duct  is  patent,  but 
in  places  obstructed  by  adhesions  which  extend  between  the 
neck  of  the  gall-bladder  and  intestine.  By  the  excessive  filling 
of  the  hollow  organ  arise,  exactly  as  in  cholecystitis,  extraordi- 
narily painful  colics.  You  know  of  a  patient,  for  example,  that  he 
formerly  has  had  several  gallstone  colics,  with  jaundice  and  the 
passage  of  stones,  then  that  for  quite  a  long  time  he  felt  well,  to  be 
later  attacked  anew  by  colics  ;  you  examine  him  in  the  interval 
when  free  from  pain,  you  find  neither  icterus,  enlargement  of  the 
liver,  tumor,  nor  sensitiveness  to  pressure  of  the  gall-bladder, 
and  are  more  inclined  to  assume  a  diseased  stomach  or  nervous 
conditions.  The  patient  lives  according  to  your  prescription, 
provides  for  a  regular  movement  of  the  bowels,  keeps  to  an 
exact  diet,  goes  several  times  to  Carlsbad,  to  the  sea  or  to  the 
mountains — all  without  success.  Since  you  were  not  able  to 
help  him,  he  goes  to  a  second  or  a  third  physician,  consults 
authorities  in  internal  medicine,  to  finally  from  homoeopath  to 
natural  healer  and  quack.  Every  imaginable  treatment  is  tried, 
nothing  helps  ;  the  patient  has  every  four  weeks  his  colic  without 
the  passage  of  a  stone  or  icterus.  Finally  he  turns  to  the  sur- 
geon. This  one  also  finds  nothing  more  than  a  slight  sensitive- 
ness to  pressure  in  the  region  of  the  gall-bladder,  the  motor 
functions  of  the  stomach  prove  to  be  normal,  the  chemistry  of 
digestion  is  undisturbed.  The  surgeon  in  question  is,  by  chance, 
no  friend  of  exploratory  incision  ;  he  repudiates  the  method  of 
diagnosis,  since  he  is  of  the  opinion  that  a  skillful  operator  ought 
to  be  able  to  make  his  diagnosis,  under  all  circumstances,  without 
opening  the  abdomen.  He  declares  to  the  patient  that  he  feels 
and  finds  nothing,  and  consequently  has  no  reason  to  undertake 


THE  TREATMENT  OF  CHOEELTTHIASIS.  12$ 

an  operation.  By  chance  there  is  in  the  city  a  second  surgeon, 
who,  on  the  subject  of  exploratory  incision,  is  of  another  opin- 
ion than  his  special  colleague  ;  he  proposes  an  exploratory  in- 
cision, and  finds  adhesions  between  the  cystic  duct  and  the 
stomach.  If,  at  such  operations,  a  physician  is  present  who  does 
not  know  the  pathology  of  adhesive  peritonitis  on  the  gall- 
bladder, he  is,  of  course,  of  the  opinion  that  the  bell)^  has  been 
opened  to  no  purpose.  But  the  course  teaches  that  it  was  not 
the  case.  The  pains  are  blown  away,  the  appetite  returns,  the 
bodily  strength,  which  had  disappeared,  develops  anew.  By  the 
excision  of  the  gall-bladder  the  patient  is  permanently  cured. 

I  will  at  this  opportunity  bring  up  something  which  I  formerly, 
when  I  spoke  of  methods  of  examination,  had  forgotten  to  men- 
tion. I  mean  the  question  whether  it  is  allowable  in  gallstone 
disease  to  undertake  an  exploratory  incision.  I  must  answer 
this  question  with  a  decided  yes.  If  a  patient  has  been  tortured 
years  long  by  the  severest  colics  without  its  being  possible,  in 
tfie  liver  or  in  the  gall-bladder,  to  find  any  sort  of  a  (morbid) 
condition,  if  he  is  greatly  impeded  in  his  avocation  by  these 
pains,  if  his  bodily  strength  fails,  if  all  possible  internal  treat- 
ment has  been  employed  without  success,  then  an  exploratory 
incision  is  not  only  permissible,  but  is  absolutely  the  duty  of  the 
physician.  The  same  is  true  of  chronic  icterus.  Then  it  is  ob- 
jectionable to  undertake  an  operation  if  one  has  diagnosticated 
with  positiveness  a  general  disease  of  the  liver  or  a  widely  ad- 
vanced carcinoma  ;  then  there  come,  still  after  all,  cases  in  w^hich 
it  is  never  positive  whether  the  chronic  icterus  is  occasioned  by 
tumor  or  by  stone.  In  the  latter  case  the  diagnostic  procedure 
acquires  the  value  of  a  curative  one.  Of  course  it  must  be  our 
endeavor  to  limit  as  far  as  possible  the  exploratory  incision,  and 
only  that  physician  should  make  use  of  it  who  is  able  to  execute 
the  necessary  procedure — for  example,  the  choledochotomy. 
Therefore  the  exploratory  incision  also  does  not  belong  to  the 
examination  methods  which  are  at  the  servace  of  the  practising 
physician. 


126  GALLSTONE  DISEASE. 

After  this  excursion  into  the  field  of  methods  of  examination, 
let  us  return  to  the  treatment  of  adhesive  peritonitis.  In  the 
example  which  I  was  able  to  quote  to  you  one  had  to  do  only 
with  adhesions  between  the  gall-bladder  and  intestine.  Fre- 
quently the  formation  of  adhesions  advances  further.  It  seizes 
upon  the  pylorus  of  the  stomach  and  kinks  it,  so  that  it  becomes 
atonic.  Then  must  one  to  the  ectomy  add  still  the  gastro- 
enterostomy. If  the  colon  should  be  involved  in  the  adhesions, 
then  there  develop  ileus-like  symptoms,  which,  of  course,  on 
frequent  repetition  require  operation. 

In  all  those  cases  in  which  we  feel  nothing,  the  physician  does 
not  usually  make  the  indication  for  operation,  but  the  patient 
himself  But  the  physician  should  know  that  these  pathological 
changes  in  the  gall-bladder  are  not  rarely  and  violent  colics  not 
always  to  be  referred  to  the  presence  of  stones,  but  often  enough 
to  the  existence  of  adhesions,  and  he  should  not  content  himself 
merely  with  such  diagnosis  as  nervous  liver  colic  and  nervous 
vomiting.  At  all  events,  it  is  true  that  such  patients  in  their 
nervous  system  so  fail,  and  that  they  become  severely  neurasthenic 
and  hypochondriac,  and  frequently  is  even  then  a  skillfully  exe- 
cuted operation  no  longer  able  to  restore  again  the  completely 
disarranged  nervous  system.  There  is  still  among  these  patients 
many  a  one  who  cannot  get  through  the  day  without  his  injec- 
tion or  two  of  morphine. 

I  would  on  this  account  advise  the  practitioner  in  such  cases 
in  which  the  results  of  palpation  are  negative,  but  the  pain  fre- 
quently recurs,  not  to  wait  long  years  for  the  operation,  but  to 
have  it  done  if  a  Carlsbad  cure  or  else  a  dietetic  treatment  in  a 
well-conducted  sanatorium  remains  without  success. 

More  easily  does  the  physician  decide  for  operation  if  he,  in  a 
patient  who  suffers  from  gallstone  colic-like  pains,  demonstrates 
a  fixed  and  hypertrophied  pylorus  and  dilatation  of  the  stomach. 

Even  here  much  can  be  accomplished  by  diet  and  irrigation  of 
the  stomach,  and  especially  the  rich  man  can  long  defer  the 
bloody  procedure,  whilst  the  poor  man  best  recovers  again  his 


THE  TREATMENT  OF  CHOLELTTIITASTS.  12/ 

long-absent  health  by  a  speedy  gastroenterostomy  and  ectomy 
of  the  gall-bladder.  In  relation  to  the  treatment  of  chronic 
recurring  cholelithiasis  I  agree  completely  with  Naunyn, 
who  will  always  first  precede  operation  by  a  Carlsbad  cure, 
assuming  that  the  disease  has  not,  as  occurs  often  enough, 
changed  back  from  a  chronic  condition  to  an  acute  one.  If 
we  find,  for  example,  in  a  patient  who  for  ten  years  has  been 
plagued  with  gallstone  colics,  a  freshly  inflamed  gall-bladder 
which,  as  a  tumor,  is  easily  accessible  to  palpation,  then 
can  the  patient  rejoice  that  his  organ  is  still  adapted  to  the 
easy  cystostomy.  It  does  not  occur  to  me  to  send  such  a 
patient  to  Carlsbad,  for  I  am  glad  that  the  gall-bladder  is 
not  yet  contracted,  and  on  this  account  I  advise  immediate 
operation. 

Moreover,  I  have  no  objection  if,  in  cases  of  chronic  recurrent 
cholelithiasis,  the  patient  first  tries  a  Carlsbad  cure,  swallows 
olive  oil  in  quantities,  and  has  his  gall-bladder  electrized  ;  mas- 
sage, however,  under  all  circumstances  is  to  be  avoided.  For  to 
knead  and  pound  an  inflamed  organ — and  with  such  a  one  we 
have  almost  always  to  do — is  a  sin  which  I,  indeed,  forgive  in 
an  uneducated  quack,  but  never  in  a  scientific  physician.  When 
I  glance  through  my  clinical  histories,  I  then  find  this  or  that 
case  marked  that  they  had  tried  a  massage  treatment.  And  if 
the  physicians  themselves  imagine  that  they,  by  their  skill  in 
massage,  can  push  the  stone  forward  into  the  choledochus,  then 
they  can  only  be  such  as  have  no  inkling  of  the  pathological 
anatomy  of  cholelithiasis.  It  is  deplorable  that  expression  of 
the  gall-bladder  should  even  yet  be  remembered,  for  if  such  a 
method  was  often  practiced,  then  many  a  gall-bladder  would 
burst  and  pour  its  destructive  contents  into  the  abdominal  cavity. 
Puncture  of  the  gall-bladder  and  expression  of  it  are  procedures 
to  be  totally  discarded  ;  whoever  believes  in  their  usefulness  and 
utility  is  e\'en  as  light-minded  as  the  scholar  who  sought  instruc- 
tion from  Faust,  but  in  Mephisto  found  a  right  dubious  teacher. 
So  little  do  we  believe  in  his  declaration 


128  GALLSTONE  DISEASE. 

Der  Geist  der  Medizin  ist  leicht  zu  fassen, 
Ihr  durchstudiert  die  gross'  und  kleine  Welt, 
Um  es  am  Ende  gehn  zu  lassen 
Wie's  Gott  gefallt  I 

So  we  should  under  no  circumstances  make  the  attempt  to 
massage  a  gall-bladder.     I  cannot  imagine  a  greater  technical  sin. 

Unfortunately,  almost  all  the  cases  with  which  we  surgeons 
have  to  do  belong  to  the  chronic  recurring  form  of  cholelithiasis. 
Often  is  the  physician — pardon  me  this  reproach,  but  more  often 
still  is  the  patient — to  blame  that  this  so  torturing  form  of  gall- 
stone disease  could  develop.  It  would  not  have  come  to  it  had 
the  acute  inflammation  of  the  gall-bladder  been  operated  upon 
early.  But  most  of  all,  the  fault  that  it  could  go  on  to  the  de- 
velopment of  the  chronic  recurring  form  is  to  be  sought  in  the 
disease  itself  The  disease  often  begins  very  harmlessly  with 
slight  distress  and  bearable  colics  ;  the  attacks  increase,  without 
being  specially  cramp-like  ;  jaundice  only  appears  in  moderate 
degree,  and  the  febrile  symptoms  disappear,  indeed,  always  in  a 
short  time.  With  this  insignificance  of  symptoms,  however, 
there  take  place  changes  in  the  right  upper  part  of  the  abdomen 
which  no  one  suspects  ;  one  finds  the  gall-bladder  small  and 
contracted,  filled  with  pus  and  embedded  in  thick  layers,  ulcer- 
ated and  perforated.  The  stones  play  in  this  an  entirely  subor- 
dinate role.  All  the  horrid  ravages  I  so  often  have  met  that  I 
can  promise  myself  but  little  from  a  Carlsbad  cure,  from  which  I 
do  not  dissuade.  Usually  it  does  not  last  long  ;  then  the  patients 
return  from  Carlsbad  unimproved  and  quickly  decide  upon  op-. 
eration,  since  the  suffering  makes  them  weary.  Even  the  most 
brilliant  operative  results,  unclouded  by  a  death,  will  not  be  able 
to  banish  the  chronic  recurring  cholelithiasis  from  the  world ; 
patients  will  again  always  first  make  a  pilgrimage  to  Carlsbar\j 
since,  as  a  Carlsbad  physician  very  fitly  expressed  it,  the  fear  c. 
the  knife  is  greater  among  mankind  than  the  fear  of  water, 
recognize  also  that  all  the  pains  of  the  surgeons  to  prove  th( 
uselessness  of  Carlsbad  water  in  such  cases  are  for  this  reasci^ 


THE  TREATMENT  OF  CHOLELITHIASIS.  I  29 

futile;  were  of  100  patients  only  2  in  Carlsbad  to  get  free  of 
their  distress,  then  the  patient  hopes  it  may  also  so  succeed  with 
him  as  with  these  two  fortunate  patients  ;  and  with  the  fear  and 
abhorrence  of  mankind  for  chloroform  and  the  knife,  it  is  to  me 
certain  that  the  chronic  recurring  form  of  cholelithiasis  will  exist 
so  long,  on  the  whole,  as  man  exists  and  the  hot  Sprudel  throws 
its  hissing  quantities  of  water  into  the  beakers  held  under  it. 
With  the  chronic  recurring  cholelithiasis  we  can  reckon  also  the 
chronic  obstruction  of  the  choledochus  by  stone.  In  relation  to 
the  treatment  of  it  I  am  of  an  entirely  different  opinion  to 
Naunyn,  w^ho,  with  the  possibility  of  the  formation  of  a  chole- 
docho-duodenal  fistula,  entertains  very  great  hopes  of  a  sponta- 
neous passage  of  the  stone  despite  long-existing  obstruction  of 
the  choledochus.  I  w^ould  willingly  abstain  from  choledo- 
chotomy  if  I  could,  in  the  particular  case,  perceive  w^hether  a 
choledocho-duodenal  fistula  would  form  or  not.  We  have  abso- 
lutely no  criteria  for  it,  and  I  cannot,  therefore,  rely  upon  the 
planless  and  capricious  sway  of  nature's  power.  Are  not  all 
these  perforations  right  dangerous  processes,  of  which  the  super- 
intendence is  entirely  withdrawn  from  us  physicians  ?  My  opin- 
ion is  as  follow\s  :  If  there  lodges  in  the  choledochus  a  stone 
which  betrays  itself  by  jaundice,  colics,  and  enlargement  of  the 
liver,  then  one  should  operate  at  latest  three  months  from  the 
occurrence  of  the  first  colic  associated  with  jaundice.  In  so 
doing  one  will  neither  make  an  anastomosis  between  the  gall- 
bladder and  intestine  nor  an  external  biliary  fistula  ;  but  one 
must,  if  at  all  possible,  do  a  choledochotomy.  If  now  there  is 
still  added  to  the  other  symptoms  of  chronic  obstruction  of  the 
choledochus  fever,  which  is  characterized  by  its  intermittent 
character,  and  reminds  one  of  malarial  fever,  then  one  does  not 
long  wait  with  the  operation,  but  operates  as  early  as  possible. 
TJie  dangers  of  an  expectant  treatment  are  greater  than  an  opera- 
tive treatment. 

If  the  chronic  obstruction-jaundice   is  occasioned   by  a  carci- 
m.»ma  of  the  choledochus  or  head  of  the    pancreas,  then   opera- 


I30 


GALLSTONE  DLSEASE. 


tive  procedures  have  little  purpose,  since  a  radical  cure  is  even 
with  early  diagnosis  made  almost  always  impossible  by  the 
anatomical  conditions.  By  successfully  executed  anastomoses 
between  the  eall-bladder  and  the  intestine  we  indeed  relieve  the 
jaundice,  but  we  lengthen  life  only  by  days  or  weeks.  Usually 
the  patients  indeed  succumb  after  the  anaesthesia  or  the  pro- 
tracted operation.  If  one  is  not  sure  of  the  facts  whether  there 
is  an  obstruction  of  the  choledochus  by  a  stone  or  tumor,  then 
one  makes  an  exploratory  incision  and  closes  the  abdomen,  if 
he  comes  upon  a  carcinoma,  as  quickly  as  possible  ;  if  one  finds 
a  stone,  then  one  should  perform  a  choledochotomy. 

Why  I  in  pronounced  or  threatened  morphinism  rather 
operate  than  have  them  balneologically  treated  requires,  how- 
ever, no  particular  explanation.  How  very  many  gallstone 
patients,  who  could  be  easily  helped  by  an  operation,  become 
morphine-takers.  Especially  important  is  it  to  frame  the  indi- 
cation for  operation  with  such  persons  as,  in  consequence  of 
their  occupation,  can  easily  possess  themselves  of  the  pain- 
assuaging  drug — that  is  with  physicians,  apothecaries,  ward- 
helpers  and  sisters.  I  have,  as  already  said,  by  opereition  pulled 
out  of  the  slough  of  morphinism  and  preserved  many  from  the 
suffering  and  misfortune  of  morphine-taking. 

I  must  decline  to  further  go  into  the  treatment  of  gallstone 
ileus.  Every  ileus,  it  matters  not  whether  it  depends  upon  fecal 
impaction,  obstruction  by  gallstones,  strangulation  Luid  inflam- 
matory processes,  should  from  the  first  be  closely  watched  by 
an  internal  physician  and  a  surgeon  together,  in  order  that — as 
is  usually  the  case — the  eventual  operation  may  not  be  under- 
taken too  late. 

That  abscess  of  the  liver  and  subphrenic  suppuration  belong 
to  the  surgeon  is  an  accepted  fact. 

With  this  I  believe  I  may  conclude  my  observations  on  the 
treatment  of  cholelithiasis.  I  condemn  the  internal  physician 
who  sends  all  his  gallstone  patients  to  Carlsbad,  and  I  censure 
the  surgeon  who   recommends  operation  to  every  gallstone  pa- 


THE  TREATMENT  OF  CIIOLELTTIIIASIS.  I3I 

tient.  One  must  individualize  and  make  his  framing  of  indica- 
tions especially  dependent  upon  the  diagnosis  of  the  existing 
form  of  the  disease. 

But  to  learn  the  special  diagnosis  of  cholelithiasis  there  is 
necessary  an  exhaustive  study  of  the  pathological  anatomy  of 
cholelithiasis  upon  the  living  organism,  on  the  operating  table. 
Since  only  few  practising  physicians  have  this  opportunity,  I 
determined  to  deliver  these  lectures,  of  which  the  experience 
gained  in  more  than  420  operations  is  the  foundation,  and  I 
cherish  the  hope  that  my  work  will  bring  help  and  achieve 
victory  in  your  own  and  wider  circles. 

The  views  which  I  have  developed  in  these  four  lectures  will 
first  come  to  your  complete  understanding  if  you  very  carefully 
study  the  clinical  histories  which  I  will  make  accessible  to  you 
by  printing.  In  their  choice  I  have  given  especial  attention  to 
those  which  are  of  great  importance  with  reference  to  diagnosis 
and  give  you  the  opportunity  to  Icani  tlic  diagnosis  of  the 
separate  forms  of  eholelitJiiasis. 

"  Qui  bene  diagnoscit,  bene  curat." 


PART  II 


ONE  HUNDRED  CLINICAL  AND  OPERATION 

HISTORIES, 

The    Exact    Study    of  which   Actually   Makes    Easier  the 

Learning  of  the  Special  Diagnosis  of  Cholelithiasis 

for  the  Practising  Physician. 

It  ought,  before  I  proceed  to  reporting  clinical  histories,  to  be 
of  interest  to  learn  something  concerning  the  results  which  I 
have  heretofore  obtained  by  my  operations. 

I  have  made,  up  till  1.4.99,  on  353  patients,  409  abdomi- 
nal sections  on  account  of  assumed  or  actually  present  chole- 
lithiasis. 

1.  After  190  conservative  gall-bladder  operations  (among 
them  37  cysticotomies,  the  remaining  153  for  the  most  part  cys- 
tostomies),  I  have  lost  in  direct  consequence  of  the  operation 
only  3  patients  =   1,5  per  cent,  mortality. 

2.  Of  81  cystectomies  3  proved  fatal  =3.7  per  cent,  mor- 
tality. 

3.  Of  62  choledochotomies  (including  drainage  of  hepatic 
duct)  6  died  =  10.2  per  cent,  mortality. 

4.  In  case  of  operative  procedures  on  the  stomach,  intestine, 
pancreas,  compliceiting  gallstone  operations,  and  in  operations  on 
account  of  severe  or  absolutely  incurable  conditions  (for  exam- 
ple, carcinoma  and  sepsis,  diffuse  purulent  peritonitis,  cirrhosis 
of  liver,  etc.),  of  76  laparotomies  37  came  to  a  fatal  issue  =  45 
per  cent,  mortality. 

Indeed,  from  this  brief  comparison  it  is  evident  that  t/ie  early 
operative  treatment  of  eholelithiasis,  that  is  the  removal  of  the 
stones  from  the  easily  accessible  gall-bladder,  is  ahiiost  witJmit 
danger.  The  three  deaths  in  the  conservative  operations  con- 
cerned (a)  a  64-year-old  man  afflicted  with  emphysema  of  lungs 

135 


136  GALLSTONE  DISEASE. 

and  artcrio-sclerosis,  who  passed  through  a  two-hour  operation 
(such  patients  I  no  longer  operate  upon  to-day)  ;  (b)  a  60-year- 
old  woman  who,  after  a  feverless  course,  had  an  apoplexy ; 
and  (c)  a  50-year-old  man  in  whom  the  gallstone  disease  had 
already  existed  22  years,  and  the  gall-bladder,  on  account  of  ex- 
treme contraction,  could  not  be  sutured  to  the  wound. 

Moreover,  the  eases  in  whieh  the  gall-blaeleler  eoiild  he  attaeJied 
to  the  parietal  peritoneum  have  eaeh  and  all  run  a  favorable  course. 
If  the  gall-bladder  on  account  of  extensive  changes  in  its  walls 
must  be  removed,  then  the  mortality  amounts  to  3.7  per  cent.  ; 
if  the  stones  are  lodged  in  the  choledochus,  then  of  every  100 
in  whom  the  choledochus  is  opened,  10  die  ;  but  if  it  comes,  as 
so  frequently,  to  peritonitis,  ileus,  sepsis,  purulent  cholangitis, 
carcinoma,  cirrhosis  of  the  liver,  etc.,  then  we  must  expect,  with 
the  necessary  operations,  about  45  per  cent,  of  fatalities. 

'*  Thus  everything  urges  that  one  should  not  delay  operative  in- 
terference in  cholelithiasis  far  too  long,  biit  that  one  should  season- 
ably and  early  think  of  operative  treatment,  so  long  as  the  path- 
ological process  has  not  yet  advanced  too  far  !  " 

In  connection  with  reporting  my  operative  results,  I  believe  it 
indicated  to  say  some  words  as  to  whether  or  not  the  practising 
physician  should  do  gallstone  operations. 

Whoever,  as  many  practising  physicians,  occupies  himself  only 
with  minor  surgery,  will,  of  course,  necessarily  refrain  from  gall- 
stone surgery.  But  I  know  a  large  number  of  practising  physi- 
cians who  extirpate  an  ovarian  tumor,  resect  the  appendix  in  the 
free  interval,  in  a  word,  execute,  in  the  country,  all  the  opera- 
tions which,  until  very  recently,  only  the  clinician  or  specially 
trained  surgeon  attempted  to  attack  in  his  hospital.  It  is  not 
here  the  place  to  discuss  whether  major  surgery  should  only  be 
practised  by  specialists  or  whether  it  also  should  be  indulged  in 
by  doctors,  to  whom  a  thorough  special  training  is  wanting. 

Gallstone  operations  belong,  without  contradiction,  to  the 
field  of  major  surgery.  It  can,  indeed,  happen  that  a  cystostomy 
upon  a  gall-bladder,  easily  accessible,  fully  distended  with  drop- 


CLINICAL  AND  OPERATION  HISTORIES. 


137 


sical  fluid  and  unadherent,  is  so  easy  an  operation  that  a  candi- 
date for  a  degree  can  execute  it ;  but  it  may,  if  the  stone  sticks 
firmly  in  the  cystic  duct,  be  so  difficult  that  even  the  very 
experienced  gallstone  surgeon  has  difficulty  in  completing  it. 
This  the  practitioner  must  know  if  he  attempts  such  an  opera- 
tion. He  must  be  well  grounded  not  only  in  asepsis,  but  also 
in  all  the  operations  of  the  abdominal  cavity.  (Pyloroplasty, 
gastroenterostomy,  resection  of  the  intestine,  resection  of  the 
liver.)  //  Jie  understands  this^  tJicn  t  lie  re  is  no  reason  7i'hy  tJie 
practising  physician  also  should  not  attempt  gallstone  operations. 
But  upon  the  technique  of  the  doctor  concerned  the  success  of! 
such  an  operation  does  not  alone  depend  ;  he  must  put  the 
patient  under  such  conditions  as  permit  watching  and  after-treat- 
ment. On  this  account  the  patient  is  best  in  a  clinic  or  in  a 
hospital,  for  in  a  private  house  after-treatment  is  difficult,  and 
the  watching,  for  example,  of  the  diet,  often  impossible. 

Gallstone  operations  must  be  performed  with  all  the  precau- 
tions of  asepsis  ;  that  is,  the  doctor,  his  assistant,  his  instruments, 
the  assisting  nurse,  must  be  permeated  with  the  "spirit  of  asepsis." 
One  must  provide  for  a  good  light,  best  of  all  a  light  from  above, 
and  since  this  is  not  usually  to  be  had  in  private  houses,  then 
the  transfer  of  the  patient  to  a  clinic  is  advisable.  With  the 
operation  itself  little  is  accomplished  ;  the  chief  care  is  the  after- 
treatment.  If  everything  goes  smoothly,  then  this  also  is  slight. 
But  how  frequently  arise  disturbances  of  the  stomach  (acute  dila- 
tation) and  of  the  intestine  (difficult  passage  of  flatus),  etc.  I  do 
not  venture  out  of  the  house,  if  I  have  a  gallstone  patient  in  my 
clinic,  but  visit  him  frequently,  the  first  few  da}'s  every  three 
hours.  One  ought  to  give  very  close  attention  to  early  recog- 
nition of  any  disturbances  and  to  warding  them  off  How  fre- 
quently is  one  obliged  to  inject  salt  solutions  and  to  wash  out 
the  stomach  ! 

On  this  account  I  am  of  the  opinion  that  only  the  doctor 
should  do  such  operations  who  can  devote  his  entire  time  to 
these  cases,  and  since  the  practising  physician  has  other  obliga- 
12 


138  GALLSTONE  DISEASE. 

tlons,  he  is  rarely  in  position  to  carry  out  the  after-treatment 
of  a  gallstone  operation  as  it  is  fitting.  As  a  matter  of  prin- 
ciple I  conduct  no  private  practice,  and  I  go  into  town  only  sel- 
dom a  single  time  to  a  consultation  ;  I  occupy  myself  solely 
with  my  clinical  patients,  and  if  I  at  any  time  am  not  in  position 
myself  to  see  after  the  patient,  then  one  of  my  assistants  looks 
after  him.  I  am  also  of  the  conviction  that  an  operative  case 
is  in  eveiy  respect  better  cared  for  in  a  clinic  than  in  his  private 
dwelling,  and  on  this  account  I  have  never  done  a  gallstone 
operation  outside.  Frequently  enough  I  have  been  entreated  to 
,do  elsewhere  a  choledochotomy  or  a  drainage  of  the  hepatic 
duct,  and  since  it  here  concerned  patients  who  were  severely  ill 
and  a  removal  would  have  incurred  great  hindrances,  I  have 
assented  upon  condition  that  I  should  do  the  operation  with  my 
own  assistants.  It  is  a  very  important  point.  The  assisting 
colleague  must,  at  least  if  it  deals  with  a  choledochotomy  or  a 
hepaticus  drainage,  be  even  as  experienced  in  the  pathological 
anatomy  of  cholelithiasis  as  the  operator  himself.  ''  There  must 
be  no  hitch,"  otherwise  a  choledochotomy  would  be  a  failure. 
Each  operator  has  his  peculiarities,  which  only  he  knows  who  is 
accustomed  to  assist  him.  The  technique  of  amputation  of  the 
breast,  of  herniotomy,  of  stomach  and  intestinal  resection,  is 
everywhere  so  much  the  same,  that  one  may  in  such  cases  op- 
erate with  each  doctor  experienced  in  surgery.  In  choledo- 
chotomy and  drainage  of  the  hepatic  duct  it  is  not  possible  ;  for 
these  one  needs  the  accustomed  assistants,  who  also  know  well 
the  weaknesses  of  the  operator.  The  demand  that  only  the 
surgeon  should  attempt  a  choledochotomy  who  has  sufficient 
training  is  thoroughly  justified,  and  success  will  only  then 
ensue  when  all — operator,  assistant,  instrument-handler — do 
their  entire  duty,  not  only  during  the  operation,  but  also  later  in 
the  after-treatment.  The  after-treatment — for  example,  in  drain- 
age of  the  hepatic  duct — is  almost  more  important  than  the 
operation.  I  do  not  do  any  such  operations  unless  I  can  con- 
trol the  after-treatment.      The   first   dressing   after  a  drainage  of 


CLINICAL  AND  OPERATION  HISTORIES.  I  39 

the  hepatic  duct  is  in  a  certain  measure  an  operation,  and  who- 
ever is  not  convinced  of  the  importance  of  constant  watching 
over  the  patient  during  the  after-treatment  ought  best  to  abstain 
from  every  operation. 

There  is  a  large  Hst  of  cases  which  must  be  operated  upon  at 
home,  since  a  removal  may  be  injurious.  I  remind  you  only 
of  peritonitis  after  cholecystitis.  In  such  cases  I  have  nothing 
to  bring  against  a  house  operation.  But  if  it  is  in  any  way  pos- 
sible, the  practitioner  should  determine  to  send  the  patient  to  a 
clinic.  Rydygier  is  indeed  of  the  opinion  that  a  laparotomy  suc- 
ceeds better  in  private  houses  than  in  hospitals,  since  in  the 
latter  there  is  greater  danger  of  air-infection  than  in  the  former. 
This  I  will  not  deny,  for  the  bacteriologists  have  proven  it  to 
us.  Personally  I  am  so  satisfied  with  my  results  that  I  can 
hardly  improve  them.  Although  there  may  be  danger  from  air- 
infection,  I  have  not  yet  suffered  from  it.  At  least  my  opera- 
ting-room is  also  so  arranged  that  I  need  have  no  anxiety 
regarding  the  perfect  carrying  out  of  asepis. 

I  have  not  the  intention  to  keep  the  practising  physician  from 
gallstone  operations  if  he  feels  the  stuff  in  him,  but  he  should 
know  that  at  any  time  he  may  stumble  on  conditions  which  only 
the  tried  operator  will  be  able  to  master.  Out  of  a  simple  cys- 
totomy a  cystectomy  and  a  choledochotomy  may  result.  The 
as.sistant  must,  as  already  said,  as  well  as  the  operator,  be  master 
of  the  pathological  anatomy  of  cholelithiasis.  On  account  of 
the  aftei'-treatment,  etc.,  it  is  best  if  gallstone  operations  should 
only  be  done  in  well-ordered  hospitals.  Elsewhere  one  should 
only  operate  if  the  removal  ivoiild  be  injurious  or  impossible. 

The  practitioner  not  especially  trained  in  surgery  will  only 
then  satisfy  that  beautiful  principle  of  surgery,  '*  Only  do  not 
injure,"  if  he  turns  over  his  gallstone  cases  to  a  specialist,  the 
surgeon.  They  will  reproach  me  with  egotism,  etc.  I  am  pre- 
pared for  it  ! — but  it  cannot  keep  me  from  openly  expressing  my 
opinion.  The  surgery  of  cholelithiasis  ought  not — this  is  my 
purpose — to  remain  the  monopoly  of  a  very  few,  but  should  be- 


140  GALLSTONE  DISEASE. 

come  the  common  property  of  surgeons  ;  for  this  reason  I  have 
published  my  contributions  in  the  Archiv.  fiir  Klin.  Chirurgie,  in 
the  Deutschen  Zeitschrift  fiir  Chirurgie.  But  gallstone  surgery 
will  never  become  the  common  property  of  the  practising  phy- 
sician, for  the  subject  is  far  too  difficult  for  that.  There  is, 
indeed,  a  great  difference  between  a  surgeon  w^ho  has  done  50 
gallstone  operations  and  one  w^ho  has  done  400,  and  one  cannot 
blame  a  patient  that  he,  if  he  in  anyway  can,  there  seeks  relief 
where  he  expects  to  find  the  greatest  experience  and  skill.  And 
}'et  despite  my  great  material,  I  often  feel  like  a  beginner  in  the 
field  in  which  I  have  labored  by  preference.  Very  recently — it 
concerned,  perhaps,  my  400  operations — I  expected  to  hav^e  an 
extremely  easy  case.  I  felt  the  distended  gall-bladder,  hoped 
simply  to  open  it  and  to  be  able  to  attach  it  to  the  abdominal 
wall.  The  patient,  daughter  of  a  doctor,  went  with  light  heart 
to  the  operation,  and  I  declared  to  the  anxious  father  '*  You 
have  no  need  of  worry,  the  case  is  easy."  The  gall-bladder  was, 
in  fact,  distended,  but  there  existed  a  fistula  between  the  gall- 
bladder and  pylorus.  Instead  of  a  cystotomy  I  was  obliged  to 
undertake  a  cystectomy,  and  on  account  of  the  narrowed  pylorus, 
the  opening  in  w^hich  w^as  sutured,  I  was  obliged  to  add  a  gastro- 
interostomy.  This  was  the  expected  easy  case  !  Formerly  I 
did  not  know  the  dangers  of  operations  of  that  sort,  since  I  was 
inexperienced  in  the  facts  of  cholelithiasis,  and  cut  down  boldly. 
My  apprentice  fees  I  myself  have  been  obliged  to  pay  ;  I  would, 
however,  spare  others  so  doing,  and  it  w^as  one  reasofi  wh}'  I 
determined  to  publish  this  lecture.  But  no  man  will  become  a 
gallstone  surgeon  b\'  the  study  of  these  leaves.  Whoever  will 
perfect  himself  in  this  field  must,  before  he  attempts  such  opera- 
tions, have  seen  a  long  series  of  such  operations  before  he  him- 
self takes  knife  in  hand.  The  more  then  he  sees,  so  much  the 
more  carefully  and  scientifically  will  he  enter  upon  his  work. 
The  more  he  himself  operates,  so  much  clearer  will  the  difficul- 
ties of  gallstone  surgery  be  to  his  eyes.  I  believed  I  ought  to 
intercalate  these  remarks,  since   gallstone   surgery  is   certain  to 


CLINICAL  AND  OPERATION  HISTORIES.  I4I 

fall  into  disrepute  if  everyone  believes  himself  justified  in  taking 
knife  in  hand.  The  bad  results  of  isolated  surgeons  are  credited 
to  the  account  of  surgery  in  general ;  and  if  gallstone  operations 
even  still  enjoy  the  reputation  of  very  dangerous  operations,  this 
evil  reputation  depends  still  upon  the  time  when  asepsis  and 
technique,  the  diagnosis  and  pathology  of  cholelithiasis,  still  were 
in  leading  strings.  Now,  since  we  have  made  advances,  which, 
as  I  believe,  have  almost  reached  their  height,  our  results  are  so 
good  and  brilliant  that  an  improvement  seems  scarcely  possible. 
The  series  of  clinical  histories  (1-12)  corresponds  to  the 
division  given  in  the  table  in  the  third  lecture  (p.  84  of  the  first 
part).  In  the  division  13-16  are  different  important  points  ex- 
plained by  some  cases  (jaundice,  differentiation  of  cholelithiasis 
from  diseases  of  the  stomach,  difficulty  and  impossibility  of  cor- 
rect diagnosis). 


Stones  in  a  Gail-Bladder,  with   Unaltered  or  but  Slightly 

Altered  Walls— Cystic    Duct    Patent— Content 

Clear  Bile — No  Adhesions. 

(a)  Mrs.  O.,  42  years,  from  Halberstadt.  Entered,  18.  i.  96 
(98?).  Operation,  18.  i.  96  (98?).  Intestinal  resection,  chole- 
cystectomy.     Discharged,  18.2.96(98?).      Cured. 

The  very  delicate  patient  has  always  been  well  up  till  15.  i.  97; 
had  always  enjoyed  good  appetite  and  regular  stool.  No  pains 
in  belly,  no  stomach  pains,  no  eructations  or  vomiting.  Only 
she  has  always  felt  in  the  right  groin  a  hazelnut-sized  bunch, 
which  was  not  movable  or  painful.  On  15.  i.,  in  the  evening, 
after  lifting  a  laundry-basket,  she  suddenly  felt  a  piercing  pain  in 
the  right  groin  and  was  obliged  to  vomit  an  hour  afterwards. 
Since  no  flatus  passed  and  the  pains  in  the  back  increased,  she 
had  a  midwife  administer  a  clyster  and  apply  hot  cloths  to  the 
painful  places.  This,  naturally,  was  of  no  avail,  and  since  the 
vomitus  got  a  fecal  smell  she  sought  the  clinic  at  midday,  18.  i. 


142 


GALLSTONE  DISEASE. 


The  immediately  executed  operation  disclosed  a  right-sided 
femoral  hernia.  There  was  a  Littre's  hernia  with  gangrene  of  the 
constriction  groove;  resection  of  a  i  2  cm. -long  piece  of  intes- 
tine ;  application  of  Murphy's  button.  Since  this  could  only 
with  difficulty  be  replaced,  the  incision  was  enlarged  upwards 
through  the  abdominal  walls,  and  now  came  in  view  the  gall- 
bladder, which  was  filled  with  large  stones.  Since  the  operation 
had  scarcely  lasted  15  minutes,  and  the  patient  had  a  good 
pulse,  I  determined  to  undertake  a  preventive  operation  on  the 
gall-bladder.  I  cut  the  abdominal  walls  further  upwards  ;  could 
convince  myself  that  the  gall-bladder  was  adherent  in  no  place  ; 
it  was  easy  to  lay  free  the  cystic  and  common  ducts  and  to  deter- 
mine that  the  ducts  were  free  from  stones.  A  forceps  was  ap- 
plied across  the  cystic  duct,  and  now  the  duct  was  cut  across. 
With  this,  pure  bile  flowed  into  the  protecting  napkin  ;  special 
ligature  of  the  arteria  cystica  ;  afterwards,  separation  of  the  large 
gall-bladder  from  the  liver ;  tamponade  of  the  liver  bed  with 
sterile  gauze  ;  excision  of  the  hernia  sack  ;  careful  suture  of  the 
abdominal  wall  up  to  an  opening  under  the  curve  of  the  ribs  for 
taking  out  the  gauze  ;  duration  of  the  operation,  45  minutes  ; 
good  ether  anaesthesia,  previously  morphine  and  atropine  ;  in 
the  gall-bladder  420  stones,  among  them  5  of  walnut  size  ; 
course  was  free  from  fever ;  passage  of  button  followed  on  the 
ninth  day  of  post  operation  ;  the  gauze  was  replaced  by  fresh 
gauze  on  the  twelfth  ;  on  the  eighteenth  day  the  patient  was  up, 
and  left  the  clinic  completely  healed,  18.  2. 

The  gall-bladder  was  very  large,  but  its  walls  were  not  thick- 
ened. Nowhere  a  trace  of  inflammation.  The  mucous  mem- 
brane was  in  absolutely  normal  condition.  The  gallstones  were 
in  this  case  innocent  foreign  bodies  of  the  greatest  harmlessness. 
Might  they  not  have  soon  altered  their  character  ?  I  have  inter- 
rogated the  patient  very  frequently  regarding  possible  pains  in 
the  stomach  and  the  like,  but  just  as  often  as  I  showed  her  the 
stones  I  ha\e  always  received  the  negative  response,  "  Those 
stones  1  cannot  possibly  have  carried  ;  I  ha\'e  never  had  even 
the  slightest  trace  of  pain." 


I 


CLINICAL  AND  OPERATION   HISTORIES.  I43 

(b)  Mrs.  V.  B.,  40  years.  Wife  of  a  captain,  from  Erfurt, 
Entered,  31.  8.  97.  Operation,  2.  9.  97.  Cystostomy.  Discharged, 
26.  10.  97.      Cured. 

Amnesis. — Mother  Hving,  is  ']2  years  old,  suffers  according 
to  daughter's  statement  from  gallstones,  father  died  from  nervous 
disease,  two  brothers  are  living,  one  suffers  from  his  stomach 
(Carlsbad  cure).  Patient  herself  was  always  healthy  ;  1  i  years 
ago  first  gallstone  attack  with  jaundice,  which  often  recurred  ; 
after  about  3  years  a  new  attack,  and  so  afterwards  ;  the  in- 
tensity of  the  pains  were  later  on  slight,  jaundice  almost  always 
existed  with  the  attacks.  The  patient  drank  at  home  Carlsbad 
Miihlbrunnen  ;  oil  of  turpentine  and  ether  also  brought  improve- 
ment. In  April,  1896,  there  was  a  severe  attack  ;  then  there  was 
a  rest  until  April,  1897,  then  a  mild  attack;  passage  of  stones 
was  not  observed.  Patient  took  opium  and  morphine  of  herself. 
P>motional  excitement  excited  light  colics.  After  an  influenza 
in  April  she  could  not  regain  her  strength.  Herr  Geheimrath 
Prof.  Dr.  Seydel  of  Jena  later  advised  an  operation,  since  treat- 
ment to  build  her  strength  up  was  without  success.  Immedi- 
ately afterwards  reception  into  my  clinic.  Herr  Dr.  Schwenk- 
enbecker  of  Erfurt  was  also  for  an  operation. 

Status  Prsesens. — Pretty  large  and  strong  woman,  heart 
and  lungs  normal,  urine  free  from  albumin,  sugar,  bile  coloring 
matters.  Liver  not  enlarged,  gall-bladder  not  palpable,  some 
sensitiveness  to  pressure  in  a  circumscribed  place.  Diagnosis, 
stone  in  the  gall-bladder.      Cystic  duct  apparently  patent. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision 
in  right  m.  rectus.  The  gall-bladder  is  moderately  large  and 
contains  stones,  not  adherent.  After  puncture  and  aspiration  of 
clear  bile  the  gall-bladder  was  opened,  14  stones  removed  and 
the  bladder  sewed  into  wound.  Abdominal  wound  sutured 
(skin  not)  (highest  evening  temperature  37.5°).  Discharged 
with  a  wound  not  yet  healed  26.  10.  97.  Patient  was  dressed  in 
P>furt.  Closure  of  fistula  27.  10.  97.  Latest  information  con- 
firms the  complete  cure. 


144 


GALLSTONE  DISEASE. 


Epicrisis. — In  this  case  the  inflammatory  symptoms  have 
always  quickly  abated.  The  amnesis  yielded  indubitable  gall- 
stone disease  (colics,  jaundice).  The  results  of  examination  were 
almost  normal,  only  the  slight  sensitiveness  to  pressure  in  the 
region  of  the  gall-bladder  (employment  of  bimanual  procedure) 
])ointed  to  the  fact  that  the  gall-bladder  was  not  healthy.  The 
diagnosis  was  based  here  also  only  upon  the  sensitiveness  to 
pressure  in  the  region  of  the  gall-bladder  and  previous  trouble  ; 
since  in  a  spare  and  easily  examined  patient  the  gall-bladder  was 
not  to  be  felt,  the  diagnosis  was  :  Soft  gall-bladder,  that  is,  zvith 
patent  cystic  duct.  Since  the  patient  had  tried  all  possible  cures 
without  success,  and  had  become  very  nervous,  I  gratified  her 
wish  for  operation.  Now,  frequent  colics,  which  rob  the  patient 
of  the  pleasure  of  living  and  lay  the  foundation  of  nervousness, 
if  medicinal  treatment  has  been  unsuccessfully  employed,  demand 
operation,  especially  if  the  patient  acquires  a  liking  for  mor- 
phine. Operation  is  often  the  best  beginning  of  a  morphine 
withdrawal  cure. 

If  a  physician  in  such  a  case  first  advises  the  trial  of  a  Carls- 
bad cure  there  is  nothing  to  say  against  it.  The  surgical  treat- 
ment, however,  assuming  of  course  that  it  is  carried  out  by  a 
surgeon  imbued  through  and  through  with  the  doctrines  of 
asepsis,  is  in  such  cases  so  free  from  danger  that  the  wish  of  the 
patient  to  be  cured  as  speedily  and  thoroughly  as  possible  suffices 
for  undertaking  an  operation.  Absolutely  indicated  it  is  natur- 
ally not,  as  for  example  in  empyaema  of  the  gall-bladder,  but  it 
is — this  often  enough  plays  a  role — in  comparison  with  a  Carls- 
bad cure,  cheaper,  and  that  wiiich,  of  course,  is  more  important, 
with  reference  to  success,  more  certain. 

(c)  Dr.  C,  from  Dresden,  50  years,  physician.  Entered,  26. 
II.  98.  Oper.,  28.  II.  98.  Cystostomy  (in  one  sitting).  Dis- 
charged, 22.  12.  98,  with  bile  fistula.      Cured. 

Amnesis. — (From  patient  himself)  :  Father,  after  absolutely 
previous  good  health,  so  far  as  relates  to  the  liver — he  suffered 
so  far  as  I  remember  from  the  same  stomach  trouble  as  I — died 


CLINICAL  AND  OPERATION  HISTORIES.  I45 

in  his  65th  year,  within  ten  days  from  a  perforating  gallstone 
colic.  I  myself  have  suffered  about  twenty  years  (am  now  49) 
from  transitory  severe  diarrhoea  (beer  !),  which  about  fifteen 
years  ago  developed  into  a  regular  chronic  intestinal  catarrh. 
At  first  week-long  and  then  month-long  diarrhoea,  with  colics  ; 
later  also  constipation  ;  by  repeated  use  of  Carlsbad  cured 
or  improved.  Since  about  two  and  a  half  years  ago  glycosuria 
to  3^  per  cent.,  which  showed  itself  by  neuralgias  and  nervous 
irritability.  Since  about  eight  to  ten  weeks  no  sugar,  despite 
no  dietary  precautions.  During  this  time  and  irregularly  during 
the  chronic  intestinal  catarrh,  pains  for  a  day  or  a  week  appar- 
ently in  the  transverse  colon,  on  walking,  standing,  etc.,  appar- 
ently not  in  stomach,  for  they  were  not  worse  after  eating.  Re- 
currence of  these  pains,  especially  in  1897,  in  March,  at  Carlsbad. 
I.  Cholelithiasis-colic  attack  end  of  August,  1897,  at  first  about 
every  three  weeks,  then  every  fourteen  days  and  eight  days,  etc. 
Recurrence  mostly  at  night.  Morphine  injected  after  one  to  two 
hours  ;  improvement,  so  that  the  following  day  practice  was 
possible.  In  beginning  of  October,  1898,  commencement  of 
persistent  colics  daily,  in  evening  or  night,  lasting  fully  four 
weeks,  gradually  diminishing  in  intensity  and  extent  after  about 
three  weeks.  The  separate  attacks  from  the  beginning  of  the 
severe  attack  lasted  sometimes  two  to  three  days — recurring 
every  night.  The  usual  beginning  was  pain  in  the  back,  which 
extended  forward,  or  forward  and  backward  at  the  same  time. 
Cessation  gradual  or  suddenly  in  course  of  ten  to  fifteen  minutes. 
Warmth,  Carlsbad  water,  at  first  acted  well.  Actual  vomiting 
almost  never  ;  on  the  contrary,  frequently  periodic  eructations, 
after  which  transitory  improvement.  After  the  attacks  the  ap- 
petite is  not  much  impaired  ;  now  and  then  a  feeling  of  hunger 
during  and  after  the  attacks.  Never  jaundice.  The  gall-bladder 
was  twice  palpated,  according  to  colleagues  ;  pain  on  pressure 
was  often  a  long  time — a  day — present,  but  just  as  often  on  the 
succeeding  morning  absent.  Since  a  fortnight  the  attacks  have 
ceased,  and  there  is  only  pain  after  sitting  or  long  walking, 
usually  under  the  right  shoulder-blade,  but  only  transitory. 


146  GALLSTONE  DLSEASE. 

Loss  of  flesh,  about  twenty  to  twenty-five  pounds,  even  thirty, 
perhaps,  in  the  last  six  months.  Noteworthy  is  for  about  ten 
years  insomnia  with  pressure  in  the  liver  region  after  every 
slight  error  in  diet. 

Status  Praesens. — Organs  healthy.  Condition  of  liver  and 
gall-bladder  completely  negative.  Urine  without  pathological 
changes.      No  jaundice,  no  painfulness. 

Diagnosis. — Old  gallstone  disease  limited  to  the  gall-bladder 
(probably  already  contracted).  Perhaps  only  adhesions  are 
present  (catarrh  of  colon).  Apparently  the  cystic  duct  is 
patent. 

Operation. — Chloroform  anaesthesia.  Fifteen  cm.  longitudi- 
nal incision  in  right  rectus  muscle.  The  liver  hardly  looks  en- 
larged, gall-bladder  lies  to  the  right  high  up  under  the  liver  and 
is  not  adherent.  One  can  with  care  so  far  draw  it  out  that  it 
may  be  punctured.  A  considerable  quantity  of  dark  bile  is  re- 
moved by  aspiration.  In  the  gall-bladder  itself  stones  are  not 
demonstrable,  on  the  other  hand  a  concretion  lies  in  the  neck. 
This  is  extracted  with  a  dressing  forceps.  It  is  a  stone  the  size 
of  a  pigeon's  Ggg,  black  and  smooth.  Immediately  bile  escapes 
in  quantity.  Gall-bladder  attached  to  the  wound  with  catgut 
and  silk  sutures  underlaid  with  wire.  Closure  of  abdominal 
wound  in  upper  part  in  layers,  in  lower  part  with  silk  sutures 
through  all  structures  ;  a  few  skin  sutures.  Duration,  one  and 
a-half  hours.      Immediate  flow^  of  bile. 

Course  was  afebrile.  During  the  first  days  much  bile  flowed 
into  the  bottle,  then  less.  In  the  daytime  when  the  patient  ate 
less  bile  flowed,  during  the  night  there  was  a  great  deal.  Remo- 
val of  sutures  the  fourteenth  day.  Up  the  fourteenth  day.  The 
patient  was  in  condition  on  the  eighteenth  day  post  op.  to 
partake  of  a  long  dinner.  No  distress.  Discharged  three  and 
a-half  weeks  after  operation.  Bile  fistula  not  yet  closed.  The 
flow  of  bile  varies  in  normal  limits.  After-treatment  in  Dresden. 
The  fistula  closed  first  after  weeks  to  again  break  out.  In  begin- 
ning of  May  fistula  healed.      Slight   dragging   in   the   depths  of 


CLINICAL  AND  OPERATION  HISTORIES.  147 

the   belly.      Perhaps   later  a  separation   of  the  gall-bladder  will 
be  necessary. 

Remarks. — The  stone  frequently  closed  the  neck  of  the  gall- 
bladder, so  that  the  gall-bladder  filled  itself  full  with  bile  and 
became  distended.  Hence  the  pains.  Whether  there  ever  was 
a  severe  inflammation  in  the  gall-bladder  is  improbable.  The 
absence  of  adhesions  would  contradict  it.  The  operation  was 
especially  indicated,  since  otherwise  the  patient  would  have  be- 
come addicted  to  morphine,  although  he  had  such  strength 
of  will  as  not  to  employ  it  save  when  absolutely  necessary  ; 
after  a  greater  or  less  time,  however,  he  would  have  yielded  to 
the  irresistible  power  of  morphine,  if  the  colics  had  become 
more  frequent. 

(d)  Mrs.  Th.,  32  years,  from  Halberstadt.  Entered,  5.  i.  98. 
Oper.,6.  I.  98.  Cystostomy.  Discharged,  26.  i.  98.  Cured. 
Amnesis. — Father  died  of  cancer  of  stomach,  always  suffered 
from  stomach,  mother  is  living,  two  surviving  brothers  and  sis- 
ters in  good  health.  Patient  is  said  to  have  had  even  in 
seventh  year  cramps  of  the  stomach  ;  these  rarely  occurred. 
Patient  married  in  her  twentieth  year,  now  had  more  trouble 
with  stomach,  could  not  bear  many  articles  of  diet,  no  vomiting, 
no  eructations,  stools  irregular.  Mother  of  three  healthy  chil- 
dren. In  1893  fii"^^  occurred  true  colics,  about  every  fourteen 
days  at  first,  later  oftener,  and  finally  each  day.  Several  times 
with  it,  among  other  things,  vomiting,  but  never  jaundice. 
Since  the  autumn  of  1897  the  patient  has  become  sparer.  Dr. 
Mentscher  sent  the  patient  to  the  clinic. 

Status  Prsesens. — Hardly  middle-sized,  poorly  nourished, 
not  jaundiced  woman.  Gall-bladder  not  to  be  palpated,  some 
pain  on  pressure  in  the  region  of  the  gall-bladder.  In  urine 
nothing  pathological. 

Diagnosis. — Stones  in  a  soft  gall-blander.    Cystic  duct  patent. 

Operation. — Chloroform  anaesthesia.  Typical  longitudinal 
incision  on  the  right.  There  presented  itself  on  opening  the  ab- 
dominal   cavity   an    unadherent    normal-sized   thin-walled   gall- 


148  GALLSTONE  DISEASE. 

bladder.  In  the  neck  were  2  stones  without  an  obstruction  of 
the  choledochus  arising.  Clear  bile  aspirated  from  the  gall- 
bladder, by  incision  were  removed  about  i  5  angular  stones  up 
to  size  of  peas  :  the  gall-bladder  was  sewed  into  the  wound. 
Tube  procedure.  Cure.  The  course  w^as  smooth.  The  high- 
est temperature  38.1°.  On  26.  i.  98  Mrs.  Th.  was  discharged 
with  not  yet  healed  wound  with  the  advice  to  return  for  dressing. 
Mrs.  Th.  feels  first-rate,  the  closure  of  the  fistula  results  in  be- 
ginning March,  '98. 

Remarks. — The  patient  had  as  a  laborer's  w^ife  to  suffer  much 
from  her  disability  ;  since  she  could  no  longer  look  after  her 
housework  she  voluntarily  decided  for  operation.  I  have 
never  examined  Mrs.  Th.  during  an  attack.  It  is  clear  to 
me  that  there  never  was  an  acute  obstruction  of  the  choledochus, 
but  always  only  inflammatory  processes  in  the  gall-bladder  of 
slight  intensity.  To  pericholecystitis  it  had  never  come.  The 
cystic  duct,  swollen  during  the  colics  by  inflammation,  again 
became  patent  on  the  cessation  of  the  inflammatory  processes, 
so  that  in  the  interval  real  distress  was  wanting  and  the  demon- 
stration of  a  gall-bladder  tumor  was  impossible.  Such  cases  as 
these  may  be  markedly  improved  in  Carlsbad,  that  is,  calmed,  so 
that  I  send  to  Carlsbad  rich  people  with  slight  fugitive  inflam- 
mations of  that  sort,  quickly  passing  colics.  It  is  better  for  the 
poor  man,  the  wife  of  a  laborer,  to  be  operated  upon.  This  is 
the  social  side  of  tJie  indications  for  operative  procedures. 

(e)  Despite  in  the  following  case  the  gall-bladder  was  packed 
with  870  stones,  one  was  at  the  examination  only  in  position  to 
feel  a  resistance  but  no  tumor.  The  diagnosis  ''gallstones''  was 
made  from  the  aninesis,  the  indication  to  operation  from  the  con- 
stantly increasing  emaciation  and  inability  to  work. 

No.  43,  H.  Z.,  44  years.  Shopkeeper's  wife,  from  Leopolds- 
hall,  near  Stassfurt.  Entered,  12.  10.  98.  Operation,  14.  10.98. 
Cystectomy.  Discharged,  13.  11.98.  Cured.  Parents  of  pa- 
tient are  dead,  father  died  10  years  ago  of  lung  disease,  mother 
6  wrecks  ago  of  paralysis  agitans.      Mrs.  Z.  married  at  32  years. 


CTJNICAL  AND  OPERATION  HISTORIES.  I49 

and  is  mother  of  two  healthy  children.  Excepting  children's 
diseases,  the  patient  was  healthy  till  she  at  about  23  years  old  ; 
one  evening"  on  going  to  bed,  suddenly  was  seized  with  cramp, 
which  began  in  the  epigastrium  and  radiated  toward  the  back. 
The  attack  lasted  about  a  quarter  of  an  hour.  The  appetite 
remained  good.  Similar  attacks  recurred  subsequently  in  more 
or  less  greater  intervals  from  a  few  months  to  at  most  a  half 
year.  In  the  latter  part  of  the  time  the  intensity  of  the  pain 
was  less,  but  the  duration  longer,  even  to  5  days.  Five  years 
ago,  for  the  first  time,  jaundice  appeared  with  an  attack  ;  since 
then  the  expulsion  of  some  lentil-sized  stones  has  been  observed. 
In  recent  years  the  attacks  have  frequently  been  attended  by 
jaundice.  The  appetite,  except  at  the  time  of  the  attacks,  has 
been  good,  only  sometimes  the  patient  complains  of  a  slight 
pressure  in  the  upper  part  of  the  abdomen.  At  home  has  often 
undertaken  drink  cures  with  Carlsbad  water  without  success. 
Mrs.  Z.  has  in  course  of  time  lost  about  20  pounds  ;  perhaps  this 
is  to  be  explained  by  a  far  too  careful  diet.  Dr.  Israel  of  Stass- 
furt  sends  the  patient  here.    • 

Status  Prsesens. — Large,  spare  woman  with  normal  organs, 
no  jaundice,  urine  free  from  albumin,  sugar  and  bile  coloring 
matters.  Resistance  in  the  region  of  the  gall-bladder,  no  tumor 
to  be  palpated,  liver  not  enlarged. 

The  diagnosis  of  an  old  gallstone  disease  was  made,  stones  in 
the  gall-bladder  and  cystic  duct,  choledochus  patent. 

Operation. — Longitudinal  incision  in  right  rectus  from  ribs 
downward  to  the  extent  of  about  12  cm.  On  opening  the  ab- 
domen there  presented  a  gall-bladder  jammed  full  of  stones, 
which  reached  three  finger-breadths  below  the  liver  border.  The 
gall-bladder  could  be  easily  brought  forward  and  was  found  free 
from  adhesions.  Small  stones  were  easily  pressed  out  of  the 
cystic  duct  into  the  bladder.  No  stones  were  contained  in  the 
choledochus,  the  head  of  the  pancreas  is  somewhat  thickened 
but  not  very  much.  Since  the  extirpation  of  the  gall-bladder 
seemed  technically  very  easy,  it  was  preferred  to  the  formation 


150  GALLSTONE  DISEASE. 

of  a  fistula  and  the  cystectomy  in  typical  manner  performed  with 
slight  bleeding  from  the  liver.  Threefold  ligature  of  the  cystic 
duct  with  catgut.  Tamponade  of  the  liver  bed  down  to  the 
stump  of  the  cystic  duct.  Closure  of  the  abdominal  wound  by 
through  and  through  silk  sutures  and  a  few  skin  sutures  up  to 
the  place  where  the  gauze  protruded  near  the  upper  angle  of  the 
wound.      Dressing.      Duration,  about  one-half  hour. 

Condition  of  Gall- Bladder. — Gall-bladder  shows  normal 
walls.  No  ulceration  or  cicatrices  of  the  mucous  membrane. 
In  the  bladder  clear  bile  and  a  large  number  (870)  of  greenish- 
yellow  round  stones  whose  size  varied  from  size  of  hempseed 
to  a  hazelnut. 

Course,  good  and  afebrile.  Patient  up  5.  11.  The  tampon- 
ade remained  19  days  and  was  first  removed  then  ;  at  the  second 
dressing  on  4.  11.  complete  healing.  Good  general  condition. 
Discharged  healed. 

Remarks. — How^  are  we  to  explain  the  distress  in  this  case? 
No  inflammation  in  the  gall-bladder,  no  adhesions.  The  stone 
tumor  must  as  a  foreign  body  have  occasioned  the  pressure 
symptoms.  Despite  the  goose-egg-sized  tumor,  which  consisted 
almost  entirely  of  stones,  one  felt  in  the  spare  w^oman  hardl)'  a 
resistance,  since  the  cystic  duct  was  patent  and  distension  of  the 
gall-bladder  wanting. 


2. 
Stones  in  the  Already  Frequently  Inflammed  Gall-Bladder. 

Cystic  Duct  at  Present  Patent.      Contents  Pure  or  but 
Little  Changed  Bile.     Adhesions. 

(a)  Mrs.  \V.,  33  years.  Manufacturer's  wife  from  Turin.  En- 
tered, 6.  7.  98.  Operation,  7.  7.  98.  Cystostomy.  Discharged, 
8.  8.  98.      Cured. 

Amnesis. — From  December  '97  to  the  end  of  March  '98,  oc- 
casional light  stomach  cramps,  which  lasted  1-2  hours,  then 
suddenly  se\'ere  stomach  cramps  after  every  nourishment,  princi- 


CLINICAL  AND  OPERATION  HISTORIES.  I5I 

pally  after  eggs  and  milk.  All  food  was  vomited  ;  exclusive 
nourishment  during  8  weeks  meat  broth  and  peptone.  During  6 
weeks  continual  pain  in  stomach  which  daily  increased  with 
irregular  duration  to  stomach  cramps. 

In  consequence  of  washing  out  the  stomach  recovered  from 
the  hyperacidity  and  would  again  tolerate  light  meats.  Finall)' 
the  passage  of  pea-sized  stones  was  observed,  of  which  gradu- 
ally 32  were  counted.  The  cramps  recurred  every  3  or  4  days, 
always  more  violently,  until  finally  the  last  lasted  31  hours. 
After  the  most  violent  colic  swooning  attacks  with  profuse 
vomiting  of  bile.  After  the  colic  which  lasted  3  i  hours  there 
always  existed  pain  in  the  back  under  the  shoulder-blade  and  in 
the  right  side  a  disagreeable  feeling,  the  stomach  was  on  shak- 
ing very  sensitive.      Three  weeks  since  the  last  colic. 

Status  Prsesens. — Marked  sensitiveness  to  pressure  in  the 
region  of  gall-bladder.  Here  ill-defined  resistance,  no  liver  en- 
largement. Stomach  dilated.  Urine  normal.  Patient  very 
stout  and  strong,  has  lost  46  pounds.      Organs  normal. 

Diagnosis. — Stones  in  a  soft  gall-bladder.  Apparently  no 
obstruction  of  the  cysticus.  Adhesions  to  stomach.  Opera- 
tion, 7.  7.  98.  Chloroform  anaesthesia.  Typical  extensive  longi- 
tudinal incision  in  the  right  m.  rectus  ;  very  fat  subcutaneous 
tissue.  Gall-bladder  somewhat  enlarged,  neck  of  gall-bladder 
adherent  to  the  stomach.  Walls  rather  thick.  Belly  protected 
by  compresses.  Aspiration  of  dark,  viscid  bile,  incision  of 
fundus,  removal  of  many  pea-sized,  soft,  light-yellow  coarseh' 
granular  stones,  among  them  a  specimen  of  hazelnut  size.  Im- 
mediately clear  bile  flowed.  Cure.  Six  pounds  gain  in  weight 
in  4  weeks.  It  is  to  be  remarked  that  at  the  operation  a  some- 
what extensive  gastroptosis  and  a  right-sided  movable  kidney  zuere 
noted.  These  are  the  eases  in  wJucJi  troubles  can  easily  again  ap- 
pear, ivhieh  of  eourse  are  by  the  patient  regarded  as  the  old  colics, 
whilst  they  solely  arise  from  the  enteroptosis.  In  our  case  on  the 
side  of  the  other  abdominal  organs  no  disturbances  seem  to  be 
noticed.      The  patient  goes  to  Tarasp  and  is  later  very  well. 


152  GALLSTONE  DISEASE. 

(b)  In  the  following  case,  which  concerned  a  surgeon,  who 
himself  was  experienced  in  the  field  of  gallstone  surgery,  one 
had  to  do  with  a  vetrogj^essivc  cJiolc cystitis.  At  the  time  of  the 
operation  the  cystic  duct  was  patent,  in  the  gall-bladder  there 
was  bile,  between  the  fundus  and  parietal  peritoneum  an  adhe- 
sion. Especially  interesting  is  the  amnesis,  from  which  it  is  to 
be  seen  how  correctly  the  patient  made  the  diagnosis  of  chole- 
cystitis and  later  pericholecystitis. 

Hofrath  Dr.  R.,  52  years,  from  Dresden.  Entered,  17.4.98. 
Operation,  19.  4.  98.  Cystostomy.  Discharged,  14.  5.  98. 
Cured. 

Amnesis. — From  patient  himself:  "  Dr.  Med.  Hofrath  R., 
chief  physician  of  the  surgical  division  of  the  Deaconesses  hospital 
at  Dresden,  5  i  ^  years  old.  Father  died,  ^6  years  old,  of  apoplexia 
cerebri,  after  he  had  repeated  attacks  of  gout.  Mother  died,  66 
years  old,  from  uraemia,  due  to  plugging  of  both  ureters  by 
urinary  gravel.  Three  of  his  four  brothers  and  sisters  are  said 
to  have  colic  from  stone  in  the  kidney.  He  himself,  save  the  in- 
fectious children's  diseases  and  several  slight  injuries,  was  healthy 
up  till  his  34th  year.  Then  he  was  ill  6  weeks  with  catarrhal 
jaundice  and  enlargement  of  the  liver,  grey  stools  and  dark  urine, 
\\'ithout  pain  or  vomiting.  Afterwards  for  10  years  entirely 
healthy.  From  his  44th  year  to  the  beginning  of  the  49th  there 
was  experienced  occasionally,  with  increasing  frequency  (in  be- 
ginning half  yearly,  later  every  3  months,  then  still  oftener),  a 
depressing  feeling  of  warmth,  apparently  in  the  region  of  the 
stomach,  of  i^-i  hour  duration,  usually  in  the  morning,  which 
was  spent  from  8-2  o'clock  without  partaking  of  food.  In  the 
beginning  of  the  49th  year  (Spring  1896),  suddenly  in  the  night 
severe  attack  of  pain  to  the  right  of  the  xyphoid,  lasting  1-2 
hours,  slowly  increasing  without  remission,  at  last  ver}^  quickly 
disappearing.  Attacks  of  pain  of  this  kind  recurred  in  1896 
every  6-8  weeks,  and  in  the  first  quarter  of  1898  almost  weekly. 
In  the  interval  of  the  attacks  there  was  undisturbed  good  health  ; 
for  instance,  all  articles  of  diet   and  the  irregular  life  of  an  ex- 


CLINICAL  AND  OPERATION  HISTORIES. 


153 


trcnicly  busy  doctor  were  borne  without  respite.  The  men- 
tioned attacks  of  pain  occurred  always  only  after  midnight, 
somewhat  near  2-4  o'clock  in  the  morning.  Vomiting  was  only 
exceptionally  associated  with  these,  3-4  times  in  40  attacks. 
Usually  with  these  the  food  taken  late  in  the  evening  was  vomited 
— no  bile.  Morphine  0.005  ^^'^^  only  exceptionally  taken  by 
the  mouth,  usually  with  the  desired  relief.  Regularly  there  was 
to  be  felt  during  the  attacks  under  the  right  ribs  an  apple- sized, 
round,  smooth,  very  sensitive  tumor,  which  moved  clearly  with 
the  respiration  and  on  change  of  position,  which  with  the  abate- 
ment of  the  pain  disappeared  without  a  trace  and  in  the  painless 
interval  was  no  longer  to  be  discovered  by  the  most  careful 
bimanual  palpation  in  a  hot  bath.  Jaundice,  discoloration  of  the 
urine  or  decoloration  of  the  stools  never  occurred.  No  search 
made  for  expelled  gallstones.  The  choice  of  foods  seemed  to 
have  no  sort  of  influence  upon  the  frequency  of  the  attacks. 
These  might  occur  after  a  meal  soup  and  remain  away  after  a 
luxurious  supper.  These  attacks  never  occurred  in  the  day- 
time or  evening.  The  pains  radiated  toward  the  right  half  of 
the  back  but  never  into  the  shoulder.  On  the  day  after  an  at- 
tack there  was  constipation,  otherwise  the  stools  were  regular 
during  the  first  year  of  the  pain,  during  the  second  somewhat 
costive.  In  the  beginning  of  April,  1898,  there  occurred  an 
attack  of  colic  w^hich  lasted  8  days  and  nights,  and  ended  with 
a  48  hours'  lasting  limited  peritonitis  in  the  region  of  the  gall- 
bladder. After  this  attack  the  gall-bladder  remained  during  ten 
days  in  diminishing  degree  palpable  and  sensitive.  The  peri- 
tonitis revealed  itself  by  elevation  of  temperature  (38.7)  as  well 
as  by  pain  on  motion  under  curvature  of  the  right  ribs  (on 
breathing,  coughing,  pressing). 

Diagnosis. — Gallstones  with  colic  pains,  the  latter  occasioned 
by  obstruction  to  the  bile  and  inflammation  of  the  gall-bladder. 
Finally  pericholecystitis. 

The  last  8-day  attack  which  necessitated  an  interruption  of  his 
professional  work,  and  left  behind  a  sensidve  gall-bladder,  brought 
13 


154  GALLSTONE  DISEASE. 

to  a  head  the  determination  to  seek  reHef  by  operation.  (Carls- 
bad AKihlbrunn  had  been  repeatedly  drunk  for  months  although 
not  after  the  manner  of  the  cure.)  Operation,  19  April,  by  Prof. 
Kehr  of  Halberstadt.  A  stone  the  size  of  a  pigeon's  egg  in  the 
neck  of  the  gall-bladder,  gall-bladder  walls  thickened  (1  cm.), 
some  fresh  adhesions  to  the  anterior  abdominal  wall,  contents 
pure  bile,  bile  ducts  free.  Suture  of  gall-bladder  into  the  wound 
and  18-day  drainage.  Smooth  recovery.  On  the  17th  of  May 
with  wound  almost  closed  goes  to  Carlsbad. 

Status  Prsesens. — Lungs  and  heart  normal,  in  urine  neither 
albumin,  nor  sugar,  nor  bile  coloring  matters.  Liver  not  en- 
larged, in  the  region  of  the  gall-bladder  a  painful,  about  walnut- 
sized,  resistance.  Otherwise  normal.  The  diagnosis  was  made 
of  a  frequently  repeated  cholecystitis  serosa  and  pericholecystitis. 
Apparently  the  cystic  duct  is  patent. 

Operation,  19.  4.  98.  Chloroform  anaesthesia.  Duration  i  ]/^ 
hours.  Longitudinal  incision  in  r.  rect.  abdom.  muscle  from  ribs 
downwards  ;  blunt  separation  of  muscle.  On  opening  the  belly 
one  finds  the  fundus  of  the  otherwise  not  enlarged  gall-bladder 
adherent  to  a  lump  of  fat  belonging  to  the  parietal  peritoneum, 
which  lies  almost  exactly  in  the  median  line.  By  this  the  whole 
gall-bladder  is  drawn  to  the  left.  It  is  released  by  blunt  dissec- 
tion from  the  adhesions  ;  immediately  the  gall-bladder  slips  up- 
ward, it  is  drawn  forward  and  palpated.  Further  adhesions 
were  not  discovered  ;  on  the  other  hand  the  gall-bladder  wall  is 
very  dense,  and  one  feels  a  large  concretion  high  up  in  the  neck 
of  the  gall-bladder.  The  gall-bladder,  pulled  forward  with  two 
hooked  forceps,  was  punctured  in  the  fundus  with  a  large  needle  ; 
and  by  means  of  an  aspirator,  after  excluding  the  belly  with 
gauze  compresses,  viscid,  blackish,  bilious  fluid  was  aspirated  ;  in 
spite  of  the  fact  that  a  considerable  quantity  had  been  removed, 
after  taking  out  the  needle  from  the  puncture  there  still  flowed 
out  continuously  a  considerable  quantity,  which  was  immediately 
wiped  up.  Now  an  incision  was  made  in  the  fundus  through 
the  puncture.     The   outflowing  quantity  was   caught  in  napkins, 


CLINICAL  AND  OPERATION  HISTORIES.  I  55 

then  the  compresses  were  changed  and  the  stone  with  not  h'ttic 
difficulty  pressed  into  tlie  fundus  ;  for  the  extraction  of  this  the 
incision  had  still  to  be  enlarged.  Now  a  hazelnut-sized  granular 
stone  was  extracted  with  a  dressing  forceps,  l^ile  now  flowed 
out  in  large  quantity  ;  this  was  wiped  away  and  the  bladder  tem- 
porarily plugged  with  dry  gauze.  The  rather  large  longitudinal 
incision  in  the  gall-bladder  was  closed  by  serous  sutures,  which 
were  easily  applied  in  the  thickened  wall,  and  so  far  diminished 
that  a  tube  of  the  size  of  the  little  finger  could  still  be  passed. 
Temporarily  the  gauze  was  left  in  the  gall-bladder,  which  was 
attached  all  around  to  the  parietal  peritoneum.  After  the  attach- 
ment was  completed,  the  parietal  peritoneum  from  the  place  of 
attachment  of  the  bladder  downward  was  closed  with  interrupted 
sutures  which  included  fascia  and  muscle  ;  then  the  remaining 
wound  was  united  with  interrupted  sutures,  with  the  exception  of 
the  region  where  the  bladder,  so  far  as  it  was  opened  by  incision, 
was  attached  extraperitoneally.  The  sutures  in  the  bladder  wall 
were  left  long,  the  tube  deeply  introduced  into  the  bladder,  gauze 
introduced  all  around  the  fistula,  and  a  large  abdominal  dressing 
applied.  Immediately  dark  bile  flowed  away  profusely.  Herr 
R.  awakened  rather  quickly  from  the  anaesthesia.  He  received 
no  fluid,  except  that  he  rinsed  out  his  mouth  with  cold  water. 
Up  till  6  o'clock  in  the  evening  he  vomited  twice  and  then  no 
more  ;  he  complained  in  the  night  of  pain.  Therefore  was  the 
tube  in  the  night  somewhat  and  on  the  morning  of  the  20.  4. 
pulled  still  more  out  of  the  bladder.  The  patient  on  20.  4.  in  the 
morning  has  his  first  nourishment  :  meal  soup,  later  coffee  and 
milk.  General  condition  good.  Herr  R.  complained  only  of  thirst 
and  weakness.  After  2  o'clock  (20.  4.)  he  retched  frequently 
and  vomited  at  first  a  little,  in  tablespoonful  amount,  then  in  the 
evening  up  to  a  ^  liter  of  blackish-brown  masses,  the  latter 
after  drinking  a  glass  of  cold  water.  Afterwards  the  patient, 
whose  pulse  in  the  evening  was  98,  temp.  36.9°,  slept  in  the  night 
well  and  felt  in  the  morning  of  the  21,  4.  very  well  (pulse  88, 
temp.    37.5°  in  ano).       The  vomiting   had   not  again    recurred. 


156  GALLSTONE  DISEASE. 

After  this  his  condition  constantly  improved,  and  the  further 
course  was  smooth  and  without  (ever.  The  sutures  were  removed 
on  the  loth  day,  wound  well  healed,  bile  flow  continues.  The 
fistula  closed  quickly  after  the  gall-bladder  had  been  drained  1 8 
days,  and  on  the  14.  5.  Herr  R.  could  be  discharged  for  an 
after  cure  at  Carlsbad  with  a  small  granulation  at  the  site  of  the 
fistula. 

The  patient  was  speedily  again  in  position,  without  any  sort  of 
distress,  to  perform  thoroughly  well  his  severe  professional 
duties  ;  he  enjoys  a  great  capacity  for  work,  an  excellent  appe- 
tite and  sound  sleep. 

Here  we  had  a  relatively  early  operation  on  which,  an  opera- 
tor, himself  of  considerable  experience  in  gallstone  surgery,  had 
determined,  since  he  well  knew  the  dangers  of  cholelithiasis  and 
would  not  lose  the  advantages  of  an  early  operation. 

(c)  Mrs.  E.,  40  years,  wife  of  a  director,  from  Zawadski  (Upper 
Silesia).  Entered,  23.  9.  97.  Operated,  25.  9.  97.  Cystostomy. 
Discharged,  30.  10.  97.     Cured. 

Amnesis. — Eather  died  of  phthisis,  mother  is  living,  had  once 
I  I  years  ago  gallstone  colic  ;  in  the  year  1880  the  patient  had 
her  first  gallstone  attack  ;  it  was  diagnosticated  cramp  of  the 
stomach  and  morphine  given.  Subsequently  attacks  occurred 
more  frequently,  then  came  a  pause  for  about  5  years.  Patient 
has  been  five  times  in  Carlsbad  ;  each  time  the  success  lasted  one- 
half  year.  A  lemon  cure  lasting  about  i  }4  months  was  without 
effect.  An  oil  cure  in  November,  1896,  has  occasioned  the  ex- 
pulsion of  stones  ;  a  marked  improvement  lasted  for  3  months. 
Toward  Whitsunday,  1897,  a  new  attack,  with  a  recurrence  in 
about  a  fortnight  :  each  time  expulsion  of  stones.  In  Novem- 
ber, 1897,  jaundice  appeared,  urine  coffee-brown.  Some  emaci- 
ation of  arms  and  legs  has  occurred,  there  is  a  feeling  of  weak- 
ness. Since  8  weeks  no  colic  attacks.  Patient  complains  of 
constant  weariness. 

Status  Praesens. — Large  corpulent  woman,  heart  and  lungs 
normal,  urine  also.  A  tumor  is  not  to  be  palpated.  Pain  on 
pressure  in  the  region  of  the  gall-bladder. 


CLINICAL  AND  OPERATION  HISTORIES.  I  57 

Diagnosis. — Stones  in  the  gall-bladder,  cystic  duct  at  present 
patent. 

Operation. — Chloroform  anaesthesia.  Ten  cm.  longitudinal 
incision  on  the  right,  some  adhesions  to  the  gall-bladder  bluntly 
freed  ;  puncture  of  the  gall-bladder  removed  some  bile.  Through 
the  incision  68  stones  removed.  Attachment  of  the  gall-bladder. 
Closure  of  the  abdominal  wound  by  layer  suture.  Smooth 
course.  (Highest  evening  temperature  37.9°.)  Flow  of  bile 
for  one  day.      Closure  of  fistula  27.  10.  97. 

(d)   H.  K.,  36  years,   head   waiter,  from   Dresden.     Entered, 

4.  5.  98.      Operated,  7.  5.  98.      Cystostomy.      Discharged,   28. 

5.  98.      Cured. 

Amnesis. — Parents  dead.  Father  died  of  lung  disease, 
mother  of  apoplexy.  Three  still  living  brothers  and  sisters  are 
healthy,  4  dead.  Patient  married  5  years,  2  healthy  children. 
Always  healthy  until  28th  year.  In  autumn  of  1892,  after  eating 
fresh  fruit,  severe  peiins  in  region  of  the  stomach,  like  cramps, 
radiating  to  the  right  side.  Deep  respiration  was  painful. 
Attack  over  in  2  hours.  No  vomiting.  Stools  always  regular 
and  brown.  Blood  and  mucus  never  observed.  The  attacks 
recurred  after  intervals  of  1-6  months.  In  1894  3  weeks  long, 
often  lasting  the  whole  day,  cramp-like  dragging  pains  in  the 
region  of  the  stomach.  Sensitiveness  to  pressure  in  right  side, 
distress  in  stomach,  now  and  then  bitter  eructations.  1895,  after 
an  attack,  dark  yellow  urine,  yellowish  foam  on  shaking.  Patient 
examined  his  stools  and  a  pea-sized,  many-cornered  yellow 
hard  stone  was  found.  In  a  later  attack  18  stones  passed  at  one 
time.  In  August,  1897,  passed  4  weeks  for  a  cure  at  Carlsbad, 
afterwards  relief  until  beginning  of  1898,  when  the  attacks  re- 
curred in  former  manner.  14.  4.  98,  an  attack  lasting  an  hour, 
afterwards  passage  of  a  stone.  In  time  the  patient  collected  70 
stones.  Appetite  and  sleep  always  irregular.  Twenty  pounds 
loss  of  weight.      No  fever. 

Status  Praesens. — Medium-sized,  lean  man.  Organs  normal, 
urine  also,   not  icteric.     Slight  sensitiveness  to  pressure  in  the 


158  GALLSTONE  DISEASE. 

region  of  the  gall-bladder.      No  tumor,  no  enlargement  of  the 
liver. 

Diagnosis. — The  diagnosis  is  made  of  stones  in  the  gall- 
bladder without  obstruction  of  the  cystic  duct.  Now  calm  in 
the  gall-bladder. 

Operation. — The  indication  for  operation  is  given  by  the 
social  position  of  the  patient,  who  is  obliged  to  work  hard. 
Operation,  7.  5.  98,  under  Schleich's  local  anaesthesia.  Dura- 
tion, I  y^  hour.  Longitudinal  incision  in  right  rect.  abdom. 
muscle  from  the  ribs  downwards  to  near  the  height  of  navel. 
The  middle-sized  gall-bladder  came  to  light ;  it  is  adherent  to  the 
stomach  ;  blunt  separation  of  the  adhesions.  Aspiration  of  thick 
bile.  Small  longitudinal  incision  in  the  fundus  after  protecting 
the  belly  with  compresses,  removal  of  1 54  angular  corn-sized 
stones,  bile  flows,  temporary  plugging -of  bladder,  suture  of  the 
same  to  the  wound,  in  the  lower  angle  two  through  and  through 
interrupted  sutures,  above  suture  of  the  peritoneum  and  fascia, 
besides  skin  sutures,  gauze  tampon  down  to  fixation  sutures  of 
the  gall-bladder  around  the  previously  introduced  tube.   Dressing. 

The  course  was  undisturbed.  Highest  temperature  is  reached 
on  9.  5.98,  with  38.2°.  Bile  flows  constantly,  first  change  of 
dressings  16.  5.,  shows  the  wound  healed  per  primam,  the 
sutures  removed  After  5  further  dressings  the  patient  was  dis- 
charged with  a  still  existing  fistula  and  a  granulating  wound. 
According  to  report  by  letter  of  21.  6.  98,  the  biliary  fistula  has 
since  12.  6.  and  the  rest  of  the  wound  since  13.  6.  completely 
closed.  Patient  remarks  that  all  goes  well  with  him  and  that  he 
feels  well  and  no  longer  has  distress. 

I  have  often  met  the  patient  in  1898  during  an  after  cure  in 
Carlsbad  ;  he  is  completely  free  from  trouble. 

The  operation  went  well  under  Schleich's  anaesthesia.  He 
felt  absolutely  nothing  of  the  abdominal  incision.  On  separating 
adhesions  the  patient  experienced  pain  in  the  stomach  and 
vomiting.  If  there  are  no  adhesions  and  the  cystic  duct  is 
patent,  one  may  employ  local  anaesthesia,  otherwise  must  always 


CLINICAL  AND  OPERATION  HISTORIES.  I  59 

employ  general  anajsthesia,  since  the  palpation  of  the  cysticus 
and  choledochus  is  extraordinarily  painful.  If  one  neglects  the 
palpation  of  the  bile  ducts,  one  will  frequently,  as  in  cystostomy 
in  two  stages,  attain  only  incomplete  cures. 


3. 

No  Stones  in  the  Gall-Bladder.     Cystic    Duct  Patent. 
Contents  Pure  Bile.     Adhesions. 

(a)  T.  E.,  42  years,  merchant,  from  Dresden.  Entered,  18.  7. 
98.  Operation,  21.  7.  98.  Gastroenterostomy  and  ectomy. 
Discharged,  27.  8.  98.      Cured  (?). 

Amnesis. — Mr.  E.  has  suffered  for  some  years  at  times,  but 
not  regularly  after  meals,  with  attacks  of  cramps  in  the  stomach 
accompanied  by  vomiting  and  want  of  appetite.  The  frequency 
with  which  the  cramps  occur  varies  greatly.  He  must  abstain 
from  many  foods  since  they  arc  inclined  to  bring  on  an  attack: 
Recently  he  has  failed  very  much  by  reason  of  his  disease  :  his 
weight  is  greatly  reduced.  He  cannot  longer  in  his  accustomed 
manner  follow  his  work  of  commercial  traveler  and  made  a  stay 
for  health  in  Blankenburg-on-the-Harz,  in  order  to  recover  his 
health.  But  directly  in  Blankenburg  he  suffered  severely  from 
cramps  of  the  stomach.  Dr.  Moll  in  Blankenburg  advised  him 
to  consult  me. 

Status  Prsesens. — Scarcely  medium-sized,  lean  man,  with  a 
facial  expression  of  suffering  and  of  nervous  restlessness.  Heart 
and  lungs  normal.  Liver  not  enlarged,  sensitiveness  to  pressure 
very  pronounced  in  the  right  parasternal  line  under  the  curva- 
ture of  the  ribs,  less  above  the  navel.  Stomach  is  large,  its  upper 
limits  lie  in  the  left  mammillary  line  of  the  7th  rib,  its  lower 
boundary  extends  beyond  the  navel  i  finger's  breadth.  In 
morning  early  is  the  fasting  stomach  free  from  remnants  of  food. 
Three-fourths  of  an  hour  after  experimental  breakfast  free  hydro- 


l6o  GALLSTONE  DISEASE. 

chloric  acid  is  found  in  abundance  (3.1  per  cent.  HCl)  ;  after 
60  minutes  had  already  the  experimental  breakfast  on  another 
occasion  entirely  left  the  stomach.  Urine  free  from  albumin  and 
sugar. 

Diagnosis. — Large  stomach  without  atony,  adhesions  with 
stomach  in  consequence  of  pericholecystitis,  hyperacidity. 

Operation. — Longitudinal  incision  in  left  rectus  muscle  reach- 
ing from  the  curvature  of  ribs  to  the  height  of  navel,  then 
lengthened  toward  the  right  and  upwards  until  somewhat  to  the 
right  of  the  ensiform  process.  The  gall-bladder  is  adherent  to 
the  omentum,  and  especially  in  the  region  of  the  cystic  duct  is 
grown  fast  to  the  beginning  of  the  duodenum.  The  dimensions 
of  the  gall-bladder  are  normal.  Concretions  not  to  be  felt,  the 
walls  feel  thick,  the  bladder  is  distended.  After  separation  of 
the  adhesions,  which  are  easily  separated  by  blunt  dissection, 
the  gall-bladder  limply  falls  together.  Separation  of  the  bladder 
from  the  liver,  which  succeeds  without  much  difficulty  or  bleed- 
ing, double  ligature  of  the  cystic  duct,  removal  of  the  bladder. 
Then  also  gastroenterostomy  after  Hacker-Carle,  since  the 
stomach  is  very  large  and  dilatation  of  it  according  to  former 
experiences  is  to  be  feared.  Closure  of  the  abdominal  wound 
with  through  and  through  silk  interrupted  sutures,  2  long  strips 
of  gauze  upon  stump  of  cystic  duct  and  liver  bed.      Dressing. 

Course. — The  temperature  rose  after  the  operation  to  reach 
its  highest  point  at  39°  on  the  day  of  the  first  change  of  dress- 
ings the  30.  7.  The  sutured  wound  had  healed  per  primam.  The 
gauze  was  taken  out  and  wound  syringed  out,  the  sutures  re- 
moved. Since  the  tampon  was  somewhat  purulent,  the  wound 
w^as  tamponed  longer.  Under  five  dressings  had  the  healing  so 
far  progressed  that  Herr  E.  could  be  discharged  with  the  direc- 
tion to  have  his  wound  dressed  thereafter  in  Dresden.  Mr.  E. 
was  completely  free  from  attacks  of  pain  during  his  stay  in  the 
clinic  ;  he  had  an  excellent  appetite  and  feared  no  longer  any  kind 
of  food.  His  weight  had  undoubtedly  increased — unfortunately 
it  had  not  been  taken  on  his  entrance — and  he  left  the  institution 


CLINICAL  AND  OPERATION  HISTORIES.  l6l 

full  of  gratitude  and  without  "  any  expression  of  suffering  in  liis 
face."  According  to  report  by  letter  i8.  9.  98,  Mr.  E.  since  the 
operation  had  no  more  pain,  the  appetite  and  digestion  were 
good  and  he  felt  well  and  strong.  Since  the  5.  9.  the  wound  is 
completely  healed.  In  October  the  patient  had  had  again  twice 
attacks  of  cramp  in  the  stomach.  We  could  not  learn  of  what 
sort  the  pains  were.  Considering  the  fondness  of  the  patient 
for  morphine  and  his  intense  nervousness  one  must  in  the  inter- 
pretation of  this  distress  be  very  guarded.  The  stomach,  etc., 
is  said  to  be  very  good. 

(b)  K.  N.,  22  years.  Laborer,  from  Thale  a.  W.  Entered, 
29.  10.  97.  Operation,  30.  10.97.  Ectomy.  Discharged,  25. 
I  I.  97.      Cured. 

Amnesis. — Parents  are  living,  father  healthy,  mother  suf- 
fers from  pain  in  the  stomach  ;  of  the  brothers  and  sisters  some 
are  dead,  four  brothers  are  living  and  healthy  ;  patient  in  his 
1 6th  year  had  typhoid,  was  ill  11  weeks,  then  healthy.  In 
.spring  of  1 897  one  morning  the  patient  could  not  rise  on  ac- 
count of  violent  pains  w^hich  extended  around  from  the  middle 
of  the  belly  to  the  back,  and  radiated  even  into  the  head.  Vom- 
iting was  absent,  stools  as  usual,  appetite  moderate,  excessive 
thirst,  icterus.  Patient  spent  a  fortnight  in  bed,  took  Carlsbad 
water  and  oliv^e  oil  ;  then  he  was  again  able  to  work.  Sacral 
pain  remained  behind,  especially  noticeable  on  lying  down.  On 
the  26th  of  October,  1897,  new  attack  of  pain  without  vomit- 
ing, with  jaundice.  Patient  remained  away  from  work.  On 
Wednesday  (27.  10.)  his  physician  advised  him  to  enter  the 
clinic. 

Status  Prsesens. — Medium-sized,  spare  man,  sclerae  slightly 
icteric  ;  on  both  sides,  severer  on  right,  sacral  pains,  sensitive- 
ness to  pressure  in  the  region  of  the  gall-bladder,  liver  not  en- 
larged. Temperature,  37.6°  ;  pulse,  85.  Condition  of  heart  : 
Sounds  pure,  nervous  distress  in  heart  (cyclist  ?).  Lungs  nor- 
mal, urine  free  from  albumin,  sugar,  bile  coloring  matters. 

Diagnosis. — Probably  no  stones,  but  pericholecystitis. 
14 


1 62  GALLSTONE  DISEASE. 

Operation. — Usual  longitudinal  incision.  Large  gall-bladder 
with  bile,  many  adhesions,  no  stones,  separation  of  adhesions, 
extirpation  of  the  gall-bladder.  Stump  of  cystic  duct  overcast. 
Tampon  of  the  liver  wound  with  iodoform  gauze.  Closure  of 
the  abdominal  wound  up  to  the  opening  for  the  removal  of  the 
gauze.  Anaesthesia  :  First  chloroform,  then  ether.  Smooth 
course  (highest  evening  temperature,  37.8°).  Discharged  cured, 
25.  II.  97. 

(c)  Mrs.  R.,  53  years,  from  Schlanstedt.  Entered,  3.  i.  97. 
Operation,  5.  i.  97.  Cystostomy.  Closure  of  biliary  fistula. 
Adhesions.  Discharged,  8.  3.  97.  Cured.  Patient  is  mother  of  6 
healthy  children,  no  hereditary  tendencies,  was  never  seriously  ill 
until  20  years  ago,  when  she  had  to  go  to  Magdeburg  for  an 
ovariotomy  for  an  ovarian  tumor.  From  then  on  till  1 894  she  was 
completely  healthy.  At  this  time  severe  pain  began  in  the  region 
of  the  stomach,  radiating  toward  the  back.  Vomiting  and  consti- 
pation occurred.  These  attacks  recurred  at  different  intervals, 
and  were  of  varying  duration.  Especially  had  the  patient  to  suffer 
in  October,  1896;  at  that  time  she  was  jaundiced.  Concerning 
the  color  of  stools  and  urine,  she  could  give  no  information. 
Since  the  pains  did  not  abate,  the  patient  concluded  to  have  an 
operation. 

Status  Prsesens. — Small,  slenderly  built,  poorly  nourished 
woman.  No  jaundice.  Heart  and  lungs  normal.  In  the  region 
of  the  gall-bladder  marked  sensitiveness  to  pressure,  no  tumor 
to  be  palpated.  Liver  and  spleen  not  enlarged.  Below  the 
navel,  to  the  symphysis  in  the  linea  alba,  a  scar  about  14  cm. 
long.  Stools  brown,  urine  clear  colored.  The  latter  contains 
no  albumin,  no  sugar,  no  biliary  coloring  matter.  No  fever. 
Pulse  is  regular,  of  moderate  strength,  yS  strokes  to  the  minute. 

Diagnosis. — Stones  in  the  gall-bladder;  adhesions. 

Operation  on  5.  i.  97.  Morphine-atropine-chloroform  anaes- 
thesia. Longitudinal  incision  in  the  right  rectus  abdominal 
muscle.  On  opening  the  belly  the  omentum  is  seen  adherent  in  its 
whole  extent  with  the  parietal  peritoneum  ;  also  numerous  adhe- 


CLINICAL  AND  OPERATION  HISTORIES.  1 63 

sions  between  the  gall-bladder,  omentum  and  duodenum.  Adhe- 
sions were  separated.  The  gall-bladder  is  fully  distended,  stones 
are  not  to  be  felt  in  it.  On  puncture  of  the  gall-bladder,  about 
80  cm.  of  muddy  bile  removed.  The  probing,  as  well  as  the  pal- 
pation of  the  gall-bladder  and  the  large  bile  ducts,  detected  no 
stones.  The  gall-bladder  was  sewed  to  the  peritoneum,  a  large 
tube  introduced  into  it,  and  afterwards  partial  closure  of  the  ab- 
dominal walls  by  suture.  Dressing.  Duration  of  the  operation, 
one  hour. 

Course. — Patient  was  very  much  collapsed  after  the  opera- 
tion, vomited  a  great  deal.  Pulse  slow,  but  very  small,  there- 
fore excitants.  Nutrient  enemata.  On  31.  i.  for  the  first  time 
left  her  bed.  On  account  of  the  profuse  discharges  of  bile,  daily 
change  of  dressing  was  required.  P'or  this,  on  the  20.  2,,  the 
gall-bladder,  under  Schleich's  local  anesthesia,  w^as  separated 
from  the  parietal  peritoneum  and  sutured.  The  sutures  held 
so  that  on  the  8.  3.  Mrs.  R.  could  be  discharged  from  the 
clinic  cured. 

Here,  with  the  greatest  probability,  former  cholelithiasis  had 
existed,  the  stones  had  passed  per  vias  naturales,  the  adhesions 
remained  behind,  and  caused  constant  distress.  The  woman, 
who  for  3  years  had  had  a  look  of  suffering  and  poor  appetite, 
was  restored  very  quickly  after  the  separation  of  adhesions,  and, 
as  recent  information  announced,  gained  about  25  pounds  in 
weight.      She  is  now^  a  strikingly  healthy  woman. 

(d)  v..  E.,  42  years.  Cranemaster  from  Ascherleben.  Imi- 
tered,  3.  6.  97.  Operation,  5.  6.  97.  Separation  of  adhesions. 
Cystectomy.  Discharged,  26.  6.  97.  Cured.  On  26.  2.  99 
operation  for  abdominal  hernia. 

Patient  the  father  of  2  healthy  children  was  sent  by  Dr.  Herz- 
feld  of  Ascherleben  to  the  clinic.  He  is  said  to  have  been  always 
healthy  until  '93.  In  this  year  he  suffered,  on  lifting  a  beam,  a 
severe  blow  in  the  right  hypochondrium.  Fourteen  days  later 
there  occurred  severe  vomiting,  loss  of  appetite,  pain  on  pressure 
and  a  tearing  feeling  in  region  of  the  gall-bladder.     The  trouble 


164  GALLSTONE  DISEASE. 

lasted  4  weeks,  and  then,  apart  from  a  slight  tearing,  complete 
well-being  returned,  which  continued  until  the  end  of  '96.  In 
November,  1896,  again  he  suffered  from  the  same  accident  as  in 
1893.  The  same  distress  began,  only  it  was  of  severer  charac- 
ter. In  January,  1897,  E.  passed  through  an  especially  bad 
attack  ;  in  February  he  was  for  the  first  time  jaundiced,  the 
stools  were  constipated  and,  so  long  as  the  jaundice  lasted, 
white  colored,  the  urine  beer-brown.  Since  the  distress  did  not 
abate,  E.  concluded  to  have  an  operation. 

Status  Prsesens. — Large,  powerfully  built  man  ;  sclera 
slightly  icteric.  Heart  and  lungs  normal.  The  liver  reaches  3 
finger-breadths  below  the  curvature  of  the  ribs.  Above  it  is 
not  enlarged  :  in  the  gall-bladder  region  marked  tenderness  on 
pressure,  but  no  tumor  is  palpable.  Spleen  not  palpable.  No 
fever.  Urine  contains  biliary  coloring  matters,  but  no  sugar,  no 
albumin.  Stools  are  white.  Pulse  regular,  strong — 80  to  the 
minute. 

Diagnosis. — Adhesions  ;  perhaps  stones  in  the  gall-bladder 
and  choledochus. 

Operation  5.  6.  97.  Chloroform  anaesthesia.  The  abdomen 
opened  by  a  longitudinal  incision  in  the  right  rectus  abdominal 
muscle  :  there  presents  a  lax,  not  enlarged  gall-bladder  ;  its  con- 
tents can  be  easily  pressed  into  the  intestine.  The  gall-bladder 
is  adherent  to  the  omentum  and  duodenum  ;  after  separating 
these  adhesions,  a  rigid  band  became  visible  which  led  from  the 
gall-bladder  to  the  ductus  choledochus  :  it  also  was  divided.  In 
the  gall-bladder  as  in  the  large  bile  duct  no  stones  to  be  felt ; 
one  abstains,  therefore,  from  opening  it  and  proceeds  immedi- 
ately to  extirpation  of  the  gall-bladder.  The  liver-bed  is  tam- 
poned with  sterile  gauze,  and  then  followed  partial  closure  of  the 
abdominal  wound.      Duration,  ^  hour. 

Smooth  course,  never  any  fever.  Discharged  without  pain, 
26.  6.  There  formed  later  a  small  abdominal  hernia  in  his 
cicatrix,  which  caused  much  distress,  and  on  26.  2.  99  was  re- 
lieved by  operation. 


CLINICAL  AND  OPERATION  HISTORIES.  1 65 

(e)  P.  B.,  30  years.  Locksmith,  from  Thalc.  Entered,  13.  i. 
97.  Operation,  15.  i.  97.  Cystectomy.  Discharged,  20.  3. 
97.      Cured. 

Patient  was  sent  to  the  cHnic  by  Dr.  Loew  of  Thale.  He  is 
said  to  come  from  a  sturdy  family,  and  himself  never  to  have 
been  gravely  ill.  P^or  twelve  years  he  has  had  a  continuous 
feeling  of  pressure  in  the  pit  of  the  stomach  and  in  the  region 
of  the  gall-bladder.  Vomiting  and  constipation  were  added  to 
this.  He  passed  through  the  first  typical  colic  with  jaundice  in 
1885,  then  the  attacks  appeared  in  varying  intervals.  In  each 
attack  jaundice  occurred,  and  the  stools  were  clay-colored  and 
the  urine  beer-brown.  In  the  last  year  the  distress  so  increased 
that  the  patient  sought  operation.  Stones  were  not  found  in  the 
stools. 

Status  Prsesens. — Medium-sized,  emaciated  man.  No  jaun- 
dice. Heart  and  lungs  normal.  Gall-bladder  markedly  sensi- 
tive to  pressure,  the  lower  liver  border  reaches  two  finger-breadths 
below  the  curvature  of  the  ribs,  above  the  liver  is  not  enlarged. 
No  tumor  of  the  spleen.  Stools  are  brown,  urine  bright-yellow 
and  contains  no  abnormal  constituents.  No  fev^er.  The  pulse 
is  regular,  strong — 82  to  the  minute. 

Diagnosis. — Adhesions,  stones  in  the  gall-bladder  (?). 

Operation  on  15.  i.  97.  Morphine-atropine-chloroform 
anaesthesia.  Longitudinal  incision  in  right  rectus  abdominal  mus- 
cle. On  opening  of  the  gall-bladder  an  elastically  distended  gall- 
bladder presented  itself.  From  the  under  surface  of  the  liver  a 
fairly  strong  adhesion  extended  to  the  gall-bladder  and  thence  to 
the  pylorus.  This  was  separated,  and  then  presented  a  diverticu- 
lum of  the  gall-bladder  so  that  the  latter  has  an  hour-glass  form. 
Stones  were  not  felt.  Since  the  assumption  seemed  probable  that 
the  distress  was  occasioned  by  the  diverticulum,  I  determined  to 
remove  the  gall-bladder.  First,  it  was  separated  from  the  under 
surface  of  the  liver  as  far  as  its  transition  into  the  cystic  duct. 
After  ligature  of  the  cystic  duct  removal  of  the  gall-bladder. 
Tamponade  of  the  stump  of  the  cystic  duct,  afterwards  partial 


1 66  GALLSTONE  DISEASE. 

closure  of  the  abdominal  wound  by  suture.  Dressing.  Duration 
of  the  operation,  i  yi  hours.  After  the  end  of  the  operation,  the 
opened  and  removed  gall-bladder  contained  absolutely  clear 
bile  ;  mucous  membrane  not  pathologically  changed.  Course, 
normal.  Cysticus  ligature  did  not  give  way.  On  20.  3.  97, 
patient  discharged  cured. 

(f)  W.  B.,  42  years,  tanner,  from  Barby  a.  E.  Entered,  15.  3. 
98.  Operation,  16.  3.  98.  Cystectomy:  Pancreas  incision.  Dis- 
charged, II.  5.  98.      Cured. 

Amnesis. — Patient,  whose  parents  are  dead,  was  formerly 
healthy,  until  in  1897  he  suffered  an  accident,  which  consisted  in 
a  severe  blow  in  region  of  the  stomach.  Since  then  an  internal 
cramp  tortures  him  daily  about  4  or  5  hours  ;  the  attack  shows 
no  dependence  upon  meals,  but  usually  occurs  after  breakfast. 
In  addition  to  these,  pains  in  breast  and  back  occurred.  On  the 
whole,  the  declarations  of  the  patient  are  not  very  exact.  Since 
he  is  said  to  be  very  much  hindered  in  his  ability  to  work,  he 
is  sent  here  on  the  assumption  that  he  had  gallstone  trouble. 

Status  Prsesens. — Large,  lean  man,  in  heart  nothing  of  con- 
sequence, over  the  lungs  diffuse  moist  rales  (bronchitis),  urine 
free  from  albumin,  sugar  and  biliary  coloring  matters.  Temper- 
ature, 37.6°  ;  pulse,  S6.  In  the  region  of  the  gall-bladder,  on 
deep  pressure  from  in  front,  marked  sensitiveness  to  pressure  ; 
by  bimanual  examination  it  is  more  pronounced.  Liver  not 
enlarged,  gall-bladder  not  palpable.  Stomach  is  neither  dilated 
nor  atonic. 

Diagnosis. — Adhesions  of  the  gall-bladder  with  the  neigh- 
boring organs  in  consequence  of  traumatic  peritonitis  of  the  gall- 
bladder, with  probably  existing  cholecystitis. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision 
in  right  rect.  abdom.  mus.  12  cm.  long.  One  finds  a  long-drawn- 
out  gall-bladder  at  the  fundus,  which  reaches  a  little  below 
the  liver  border ;  shows  on  the  anterior  surface  adhesions  to 
the  omentum,  on  the  under  surface  with  the  stomach  and  duo- 
denum.    These  adhesions  are  separated  partly  with   knife  and 


CLINICAL  AND  OPERATION  HISTORIES.  1 6/ 

scissors  and  partly  bluntly,  then  the  L;all-bl adder  extirpated 
almost  without  bleeding".  Double  ligature  of  the  cystic  duct. 
Now  one  was  able  to  feel  in  the  horseshoe  of  the  duodenum, 
whose  horizontal  superior  part  is  by  a  thin  connective  tissue 
membrane  drawn  toward  the  pars  inferior,  the  thickened  hard 
pancreas.  An  especially  prominent  hard  knob  of  almost  walnut 
size  aroused  the  suspicion  of  a  new  growth,  and  on  this  account 
an  incision  was  made  therein.  There  appeared  no  other  changes 
than  inflammatory  ones,  and  after  the  excision  of  a  pea-sized 
piece  for  microscopical  examination,  the  severely  bleeding  wound 
was  closed  with  sutures.  On  account  of  the  fear  of  an  obstruc- 
tion of  the  common  duct  by  pressure  of  the  enlarged  head  of 
the  pancreas,  an  attempt  was  made  to  do  a  cystico-duodenostomy, 
and  for  this  purpose  the  duodenum,  at  the  transition  of  the  pars 
horizontalis  sup.  into  the  pars  descendens,  was  opened  by  a  i 
cm.  transverse  incision.  It  is,  however,  impossible  to  produce 
an  anastamosis  of  the  cystic  duct  with  the  duodenum,  because  of 
the  narrow  lumen  of  the  former  ;  therefore  suture  of  the  duo- 
denum opening.  The  stump  of  the  cystic  duct  from  which  the 
ligatures  had  not  been  removed  was  overcast.  Two  long  strips 
of  gauze  introduced  to  the  stump  of  the  cystic  duct  tamponed 
the  liver  bed  ;  they  were  brought  out  of  the  upper  angle  of  the 
wound;  closure  of  the  rest  of  the  abdominal  wound  by  through 
and  through  and  some  interrupted  skin  sutures.  In  the  gall- 
bladder, containing  thick  dark-brown  bile,  were  found  21,  about 
poppy-seed-sized,  blackish  stones. 

Course. — Evening  temperature  feverish  from  day  of  operation, 
the  16.  3.  to  22.  3.,  then  normal  22.  3.  to  28.  3.,  again  feverish  to 
the  9.  4.  98.  The  explanation  of  the  fever  was  afforded  by  a 
right-sided  severe  pneumonia,  which  was  at  first  localized  in  the 
lower  lobe,  but  in  the  second  fever  period,  however,  involved  the 
middle  and  superior  lobe.  At  the  first  change  of  dressings,  on 
the  loth  day,  the  wound  was  found  healed  per  primam,  yet  there 
exuded  from  the  place  of  the  tampon,  even  after  gauze  was  not 
introduced,  for  a  long  time  muddy  fluid,  which  clearly  corroded 


1 68  GALLSTONE  DLSEASE. 

the  surrounding  skin.  In  the  fluid,  of  which  one  succeeded  in 
obtaining  small  amounts,  were  all  three  of  the  pancreatic  ferments 
found  ;  it  was,  without  doubt,  pancreatic  juice.  The  fistula  closed 
only  slowly.  After  a  silk  ligature  had  been  thrown  off  from  a 
ligature  abscess,  the  healing  ended  on  the  3.  5.  98.  After  fitting 
an  abdominal  bandage  the  patient  was  discharged  i  i.  5.  98.  The 
internal  cramp  tortures  him  no  more,  and  this  is  confirmed  by  a 
letter  of  31.  5.  98.  The  breast  and  back  pains  are  said  to  still 
exist.  The  microscopical  examination  of  the  excised  piece  dis- 
closed solely  inflammatory  changes  in  the  pancreas. 

(g)  H.  B.,  39  years,  cabinet-maker,  from  Quedlinburg.  En- 
tered, 12.  6.  98.  Operation,  15.  6.  98.  Ectomy  (adhesions). 
Discharged,  24.  7.  98.      Cured. 

Amnesis. — Parents  dead  :  father  died  of  chest  disease,  mother 
old  age.  Patient  has  three  living  brothers  and  sisters  who  are 
healthy  ;  he  himself  was,  on  the  whole,  healthy,  but  suffered 
from  irregular  stools.  Patient  has  often  put  the  brace  against  the 
region  above  the  navel,  but  does  not  know  otherwise  of  anything 
relating  to  his  business  likely  to  occasion  his  present  trouble. 
His  complaints  relate  to  the  stomach,  and  they  are  burning  in 
the  stomach  and  eructations  of  watery  fluid  after  many  foods, 
finally  vomiting  ;  with  it  occurs  cramp-like  pains  under  the  ensi- 
form  process. 

Status  Praesens. — Large,  emaciated  man.  Organs  normal. 
Sensitiveness  of  pressure  in  the  region  of  the  gall-bladder. 

Diagnosis. — Adhesions  of  the  gall-bladder. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision 
in  the  r.  m.  rectus.  The  gall-bladder,  adherent  to  omentum, 
stomach,  colon,  was  separated  from  its  adhesions  and  found  free 
from  stones.  Easy  extirpation  of  the  gall-bladder,  cystic  duct 
ligatured  several  times,  slight  bleeding  from  the  liver.  Tamponade 
of  liver  bed  down  to  stump  of  the  cystic  duct.  Pylorus  patent. 
Gall-bladder  healthy,  no  stones,  contains  bile. 

Course  is  marked  by  evening  elevations  of  temperature  in  the 
first  ten  days,  in  which  the  evening  temperature  reached  to  39.6° 


CLINICAL  AND  OPERATION  HISTORIES.  1 69 

(on  24.  6.).  On  this  day  the  first  change  of  dressings  took  place  ; 
the  tamponade  was  infected  and  saturated  with  pus.  Wound 
washed  out  with  sterile  water,  and  plugged  with  sterile  gauze. 
Removal  of  the  skin-sutures,  which  had  cut  through  in  part. 
In  consequence  the  temperature  returned  to  normal  limits. 
Under  6  dressings  complete  healing  resulted.  The  patient  was 
discharged  with  a  firm  wound,  and  a  very  good  appetite  after  the 
adjustment  of  an  abdominal  bandage,  24.  7.  98.  On  16.  9.  98, 
presents  himself  again  :  no  hernia;  16  kilogrammes  gain  of 
weight. 

Remarks. — Irlave  stones  at  one  time  been  present  in  this  case 
or  was  it  only  a  cholecystitis  traumatica  ? 

uid/iesive  peritonitis  in  tJic  gall-bladder  is  sucJi  an  exquisite 
Jinnian  disease  tJiat  I  am  inclined  more  to  traumatic  influences 
than  stones. 


Acute    Cholecystitis   in  a  Relatively  but  Slightly  Altered, 
Distensible  Gall-Bladder. 

First  I  report  some  typical  cases  of  acute  sero-purulent  chole- 
cystitis. 

(a)  A.  B.,  37  years,  wife  of  a  laborer,  from  Heudeber.  En- 
tered, 29.  9.  98.  Operation,  29.  9.  98.  Cystostomy.  15.  11. 
98,  secondary  cysticotomy.  5.  i.  99,  closure  of  biliary  fistula. 
Discharged,  22.   r.  99.      Cured. 

Amnesis. — Patient,  the  mother  of  3  healthy  children,  de- 
clares that  up  till  the  present  illlness  she  had  never  been  actually 
ill.  Some  14  days  ago  she  had  slight  pains  in  the  back,  which 
radiated  toward  the  right  shoulder.  With  it  she  felt  herself  un- 
comfortable and  weak,  but  otherwise  no  distress.  On  the  26.  9. 
she  very  suddenly  became  ill  with  violent,  bilious  vomiting,  very 
strong  cramp-like  pains  in  the  region  of  the  gall-bladder,  disten- 
sion  of  the   stomach,    slight   fever   and   chills.      The   attending 


I/O  GALLSTONE  DISEASE. 

physician,  Dr.  Hesselbach,  diagnosticated  gallstone  disease  and 
ordered  hot  poultices  and  laxatives.  Since  afterwards,  on  the 
succeeding  days,  no  improvement  had  appeared  and  a  constantly 
increasing  tumor  on  the  lower  liver  border  made  its  appearance, 
he  caused  her  transfer  to  the  clinic. 

Status  Prsesens. — Medium-sized,  spare  woman,  with  pain- 
drawn  exjDression  of  face  ;  groans  constantly. 

Whole  abdomen  distended,  slightly  sensitive.  Region  of 
gall-bladder  exquisitely  painful.  There  one  feels  a  cucumber- 
formed  tumor,  which  originated  broadly  from  the  lower  border 
of  the  liver  and  extends  downwards  to  3  finger-breadths  below 
the  navel.  Tumor  very  movable.  Some  4  or  5  cm.  broad. 
No  jaundice.  Pulse,  84.  Temperature,  ^S.y.  Urine  free  from 
albumin,  biliary  coloring  matters  and  sugar. 

Diagnosis. — Acute  sero-purulent  cholecystitis. 

Operation. — Chloroform  anaesthesia  (continuous  bad  breath- 
ing). Longitudinal  incision  in  right  rect.  abdom.  muscle.  Gall- 
bladder very  greatly  enlarged,  cucumber-formed,  reaches  2 
finger-breadths  under  the  navel  and  is  completely  distended  but 
elastic.  On  the  gall-bladder  layer  of  fibrin  :  delicate  adhesions 
between  the  gall-bladder  and  omentum.  Puncture,  removal  of 
about  70  ccm.  of  greenish-yellow  pus.  Enlargement  of  the 
puncture  by  incision,  remo\'al  of  45  yellow  faceted  stones  of  3 
different  sizes.  One  of  the  largest  as  plug  in  neck  of  bladder. 
After  the  removal  of  these,  scanty  flow  of  bile  (clear  bile),  cys- 
tostomy.  Tube  in  gall-bladder.  Wire  method.  Partial  closure 
of  abdominal  wound,  with  through  and  through  interrupted 
and  skin  sutures.  Smooth  afebrile  course.  On  14th  day  the 
sutures  were  easily  removed  ;  one  needed  only  to  pull  upon  the 
wire.  Slight  flow  of  bile.  Patient  up  the  15.  10.  The  bili- 
ary secretion  is  very  small.  Feels  splendid.  On  the  i.  11.  it 
appeared  on  the  change  of  dressings  that  only  mucus  flowed. 
In  the  depths  one  clearly  felt  with  a  probe  a  large  stone.  Plx- 
traction  failed  ;  also  on  6.  1 1.  The  case  will  require  a  secondary 
cysticotomy.     The  case  is  a  proof  of  how  senseless  a  cystendysis 


CLINICAL  AND  OPERATION  IIISTORIFX  171 

is.  One  found  the  lar^^e  plugging  stone,  bile  flowed,  and  in  spite 
of  the  most  careful  palpation  of  the  cystic  duct  (it  was  the  375th 
gallstone  operation  in  my  clinic)  there  remained  still  undetected 
a  stone  of  2  cm.  in  diameter,  which  the  subsequent  cysticotomy 
proved.  It  is  time  that  the  cystendysis  should  be  entirely  ex- 
cluded from  the  methods  of  removing  stones  from  the  gall- 
bladder and  cystic  duct.  The  stone  is  not  to  be  seized  with 
dressing  forceps  or  similar  instruments,  on  that  account  on  the 
15.  II.  98,  secondary  cysticotomy.  Opening  of  the  abdomen 
in  the  median  line  between  navel  and  xyphoid  process.  Large 
stone  reaching  2  cm.  in  diameter  in  cystic  duct ;  cysticotomy. 
Suture  with  formalin  catgut  (6  sutures).  Biliary  fistula  remains 
undisturbed.  Gall-bladder  large,  loosely  adherent  to  stomach. 
Closure  of  abdominal  wall.  Operation,  25  minutes.  Immedi- 
ately bile  flowed.     Tube  in  gall-bladder.      Dressing. 

How  is  it  possible  that  one  ov^erlooks  such  a  large  stone  ?  It 
can  happen  to  the  best  technicians,  since  the  wall  of  the  gall- 
bladder is  extremely  thickened  and  makes  palpation  impossible. 
Is  there  a  case  which  more  earnestly  warns  against  cystendysis 
than  does  this  ?  Primary  cystectomies  are  not  permissible  in  such 
cases  ;  the  gall-bladder  is  very  large,  the  bleeding  would  be  very 
severe,  the  cystic  duct  is  so  thickened  that  a  huge  stump  would 
have  to  be  ligated.  In  severe  inflammation  it  is  almost  impos- 
sible to  attain  to  the  cystic  duct. 

Secondary  cystectomies  are  more  severe  than  secondary  cysti- 
cotomies,  which  I  can  very  much  recommend  for  such  cases. 
Let  one  look  to  it  that  the  incision  in  the  neck  of  the  gall-blad- 
der or  cystic  duct  is  so  planned  that  it  does  not  come  to  the 
median  side  (since  thus  adhesions  to  the  stomach  can  result), 
but  more  upwards,  so  that  the  incision  adheres  to  the  under  sur- 
face of  the  liver.  Since  the  flow  of  bile  is  always  so  profuse, 
and  the  patient  desired  earnestly  an  early  discharge,  on  the 
5.  I.  99,  under  anaesthesia,  the  gall-bladder  was  separated  from 
the  abdominal  walls,  the  fundus  resected  and  the  opening  sutured 
with  formalin   catgut.     Gall-bladder   dropped.     Sterile   tampon 


172  GALLSTONE  DISEASE. 

down  to  suture.  Removal  of  this  the  19.  1.  On  22.  i.  99 
discharged  in  glowing  health  ;   wound  closed  at  the  bottom. 

(b)  M.  K.,  22  years,  wife  of  laborer,  from  Aderstedt.  En- 
tered, 15.  9.  98.  Operated,  16.  9.  98.  Cystostomy.  Discharged 
20.   10.  98.     Cured. 

Amnesis. — Patient  is  said  to  have  been  formerly  healthy  unti: 
Christmas  time  1897,  she  became  ill  with  severe  pains  in  the 
right  upper  portion  of  the  abdomen.  The  attack  lasted  3  days 
it  was  not  accompanied  by  vomiting  and  jaundice,  but  by  los^ 
of  appetite.  Then  complete  feeling  of  well-being  until  12.  9.98 
Recently  illness  of  the  same  kind. 

Status  Praesens. — Organs  normal  ;  tumor  of  great  sensitive- 
ness to  pressure  in  the  gall-bladder  region  to  be  palpated.  Ii 
reaches  somewhat  below  the  navel.  Evening  temperature 
38.2°;  pulse,  120.  In  urine  no  albumin,  no  sugar;  patient  i.^ 
given  castor-oil  ;  on  the  succeeding  morning,  tumor  more  appar- 
ent, but  less  sensitive  (action  of  laxative). 

Diagnosis. — Acute  sero-purulent  cholecystitis.  Relativel> 
fresh  attack.  The  attending  physician,  Dr.  Klavehn  of  Pabs' 
torf,  who  sent  the  patient  for  operation,  had  made  the  correct 
diagnosis. 

Operation. — Longitudinal  incision  in  the  right  rect.  abdom 
muscle,  extending  from  the  curvature  of  the  ribs  to  3  finger- 
breadths  below  the  navel.  Serosa  somewhat  injected,  no  adhe- 
sions. Aspiration  of  a  considerable  quantity  of  muddy,  at  lasl 
purulent  serum,  the  cystic  duct  plugged  with  pea-sized  yellow 
mulberry  stones  (18  in  number);  they  were  pressed  into  the 
gall-bladder  and  taken  out  after  incision.  Attachment  of  gall- 
bladder to  parietal  peritoneum,  wire  method,  lower  part  of  the 
w^ound  united  in  3  layers,  in  upper  wound  border  2  skin  sutures, 
Tube  introduced  into  the  gall-bladder,  tamponade  to  the  fixa- 
tion sutures.     Dressing.      Duration,  one  hour. 

Course. — Completely  feverless  and  free  from  pain.  Constani 
flow  of  bile.  First  change  of  dressings  on  the  30.  9.  Removal 
of  tube  and   stitches.     Stone   demonstrable  with  a  probe.      Its 


CLINICAL  AND  OPERATION  HISTORIES.  1 73 

removal  with  dressing  forceps  failed.  2.  10.  On  changing  the 
dressings  to-day  two  fully  pea-sized  mulberry  stones  lay  in  the 
wound;  others  not  to  be  detected.  12.  10.,  flow  of  bile  con- 
stantly less.    Discharged  cured,  20.  10. 

Remarks. — Acute  sero-purulent  cholecystitis  is  an  extraordi- 
narily frequent  disease,  which  seems  especially  to  plague  the 
working  class.  Usually  the  peritoneum  participates  more  or 
less  markedly.  An  early  operation  is  the  proper  treatment  to 
prevent  the  further  ravages  of  the  peritonitis.  In  such  cases  the 
cystostomy  deserves  the  preference  over  ectomy.  An  extirpa- 
tion would  be  a  very  bloody  operation,  the  danger  of  infection 
would  be  increased  by  it.  However,  it  may  in  some  cases  find 
application,  since  at  a  blow  it  removes  the  original  abode  and 
takes  away  the  cradle  of  the  infection.  The  case  shows  how 
difficult  it  is  at  the  first  operation  to  detect  all  stones  and  re- 
move them. 

(c)  Mrs.  M.  G.,  24  years,  wife  of  cigarmaker,  from  Halberstadt, 
Entered,  6.  9.  98.  Open,  7.  9.  98.  Cystostomy.  Discharged, 
27.  9.  98.  Cured.  Patient  mother  of  3  healthy  childen,  comes 
from  a  healthy  family  and  has  no  hereditary  affections.  Except 
children's  diseases,  is  said  never  to  have  been  severely  ill.  On 
18.  10.  97  she  had,  without  any  demonstrable  cause,  a  cramp 
of  the  stomach,  with  violent  pains  and  severe  vomiting,  which 
lasted  about  an  hour.  Afterwards  similar  attacks  occurred  in 
short  intervals  of  greater  intensity  and  longer  duration  (up  to 
I  y>  hours).  The  last  attacks  were  attended  by  mild  jaundice. 
On  2.  9.  severe  attack.  Fever.  Very  lively  sensitiveness  to 
pain.  Dr.  Crohn  finds  the  gall-bladder  very  much  enlarged, 
and  makes  the  diagnosis  acute  cholecystitis.  Entrance  into  the 
clinic  6.  9.  98.  On  reception  at  4  o'clock,  temp.  38.4°  C.  ;  in 
the  evening  at  7  o'clock,  38.8°  C.  Castor-oil  for  laxative. 
Baths.     Alcohol  poultice. 

Status  Prsesens. — Middle-sized,  graceful  woman  of  moderate 
condition  of  nutrition.  At  the  heart's  apex  with  the  first  sound 
a  loud    systolic   murmur.     Apex  beat  enlarged.     Tones  other- 


174  GALT.STONE  DISEASE. 

wise  pure,  not  accentuated.  Heart's  dullness  not  enlarged. 
Pulse  84,  regular  and  small ;  lungs  healthy. 

Belly  soft,  not  distended.  Under  the  curvature  of  the  right 
ribs,  corresponding  to  the  region  of  the  gall-bladder,  one  feels 
deeply  a  tumor  somewhat  egg-shaped,  which  diminishing  below, 
extends  2  finger-breadths  beyond  the  level  of  the  navel,  has  a 
relative  breadth  of  about  3  cm.,  and  above  passes  without  a 
limit  into  the  liver.  Over  the  tumor  dull  resonance.  Liver  not 
enlarged.  The  tumor  is  extraordinarily  sensitive  to  pressure, 
and  movies  with  the  respiration.  No  jaundice.  Urine  free  from 
albumin,  sugar,  biliary  coloring  matters.  Stools  of  normal 
color  and  form,  not  constipated. 

Diagnosis. — Acute  cholecystitis,  with  gallstones. 

Operation. — Ether  anaesthesia  ;  longitudinal  incision  in  right 
rectus  abdominal  muscle  from  curvature  of  the  ribs  downwards 
some  12  cm.  long.  On  opening  the  belly  one  sees  that  the 
tumor  is  formed  by  the  fully  distended,  markedly  enlarged, 
cucumber-formed  gall-bladder,  which  reaches  below  the  navel 
2  finger-breadths.  The  gall-bladder  has  in  the  form  of  a 
tongue-shaped  lobe  drawn  the  liver  border  far  downwards. 
In  the  free  abdominal  cavity  small  quantities  of  clear  yellow 
fluid  (inflammatory  exudate)  ;  no  fibrinous  clots.  Easily  sepa- 
rated adhesions  of  the  gall-bladder  to  the  omentum,  the  latter 
at  the  points  of  attachment  somewhat  succulent.  By  puncture 
of  the  gall-bladder  about  40  cm.  of  greenish  pus  was  evacuated, 
the  puncture  opening  was  enlarged  by  incision,  the  belly  pro- 
tected by  numerous  compresses.  From  the  opening  with  for- 
ceps some  60  stones  were  removed,  which  varied  in  size  from 
millet  to  a  hazelnut.  Several  stones  lodged  in  the  cystic  duct 
could  be  pressed  into  the  gall-bladder  and  then  removed.  Chole- 
dochus  free.  Drying  out  of  the  gall-bladder.  No  flow^  of  bile. 
Attachment  to  the  parietal  peritoneum.  Partial  closure  of  the 
abdominal  wound.  Drainage  of  the  gall-bladder  by  tube. 
Dressing.     Duration  of  the  operation  one  hour. 

Course. — Continuously  free  from  fever.  Bile  flow  from  3d 
day   on   always  in  slight  amount.      Stools  always  colored  dark, 


CLINICAL  AND  OPERATION  HISTORIES.  I  75 

never  pain  ;  good  general  condition.  First  change  of  dressings  on 
the  17.  9.  Removal  of  tube.  Probing  of  the  gall-bladder  could 
not  detect  any  stones.  Since  subsequently  the  discharge  of  bile 
was  very  slight,  and  the  patient  remained  free  from  distress,  she 
was  on  the  27.  9.  98  discharged  with  a  small  healthy  looking 
fistula.  Definitive  closure  of  this  the  end  of  October.  Patient  is 
now  perfectly  well  and  able  to  work. 

Not  so  typical  as  the  foregoing  are  the  following  cases,  in 
which  there  was  without  doubt  an  acute  cholecystitis,  although  a 
distuict  tuDiorwas  absent,  and  only  a  very  painful  resistance  could 
be  felt. 

Where  a  gall-bladder  is  to  be  felt,  the  indication  for  operation 
will  be  easier  made  than  in  the  case  in  which  only  a  painful  re- 
sistance occurs  in  the  region  of  the  gall-bladder.  And  yet  the 
latter  cases  are  the  more  frequent,  and  their  recognition  for  the 
practitioner  of  greatest  importance. 

(a)  A.  P.,  25  years,  tavern-keeper's  wife,  from  Braunschwende 
by  Wippraa.  H.  P:ntered,  8.  8.  98.  Oper.,  15.  8.  98.  Cystos- 
tomy.      Discharged,  17.  9.  98.     Cured. 

Amnesis. — Patient,  whose  parents  are  living  in  good  health, 
was  herself  never  very  ill  until  in  1894,  suddenly  in  the  night 
she  had  an  attack  of  pain,  ushered  in  by  vomiting.  The  pains  were 
in  the  right  upper  part  of  the  abdomen,  and  varied  during  the 
week  ;  patient  was  in  bed  in  their  intensity.  The  attendant  used 
morphine  injections.  Again  good  health  returned,  toward  1896 
the  same  attacks  of  3  days'  duration  occurred.  A  diagnosis 
was  not  made.  Since  then  cramp-like  attacks  of  pain  occur 
frequently  at  intervals  of  4-8  weeks.  The  pain  was  always 
severest  on  the  right  under  the  ribs,  and  later  drew  more  towards 
the  median  line.  Shortly  before  the  patient,  who  had  never  been 
yellow,  came  hither  gallstones  were  diagnosticated.  The  last  8 
days  before  coming  hither  the  woman  had  uncommonly  violent 
pains. 

Status  Prsesens. — Middle-sized,  .somewhat  delicate,  well- 
nourished  woman.  Organs  normal.  Urine  free  from  albumin, 
sugar  or  biliary  coloring  matters.      Liver   region  very  sensitive 


1/6  GALLSTONE  DISEASE. 

to  pressure,  liver  not  enlarged,  gall-bladder  palpable  as  a  tumor, 
which  lies  on  the  outside  of  the  rectus,  yet  on  account  of  the 
tense  abdominal  walls  and  exquisite  sensitiveness  to  pressure  in- 
distinctly. Lower  limits  of  the  tumor  a  thumb's  breadth  below 
the  navel.     Temp.  37.9°  ;  pulse,  88. 

Diagnosis. — Acute  cholecystitis.  After  several  days'  evacua- 
tion of  the  bowels  the  sensitiveness  to  pressure  almost  entirely 
disappeared,  the  gall-bladder  was  no  longer  demonstrable. 
Temp.  37.3°.  The  operation  was  delayed  by  building  changes 
in  my  operating  room,  and  was*  first  undertaken  on  the  15.  8. 

Operation. — Chloroform  anaesthesia.  Eight  cm.  longitudinal 
incision  in  right  rectus  abdom.  muscle.  The  gall-bladder  ex- 
tended with  its  fundus  beyond  the  liver  border  ;  it  is  fully  dis- 
tended ;  light  adhesions  to  omentum  which  yield  to  the  pressure 
of  the  palpating  finger.  Protection  of  the  belly  by  compresses. 
Suspension  of  the  gall-bladder  by  2  provisional  silk  ligatures. 
Puncture  and  aspiration  of  the  contents  of  the  gall-bladder ;  a 
considerable  amount  of  muddy  brown  fluid  was  pumped  out. 
Palpation  detects  in  the  neck  of  the  gall-bladder  a  stone,  which 
can  be  pressed  into  the  gall-bladder.  Opening  of  the  fundus  of 
the  gall-bladder  by  a  longitudinal  incision,  drying  of  the  bladder 
by  dry  gauze  strips.  Extraction  of  2  black  stones,  one  hazel- 
nut and  one  cherry-stone  size  ;  immediate  flow  of  bile.  Attach- 
ment of  the  gall-bladder  to  the  parietal  peritoneum,  then  inter- 
rupted suture  of  the  peritoneum  to  the  lower  angle  of  the  wound, 
muscle  and  fascia  interrupted  suture,  skin  suture.  Introduction 
of  a  thick  tube  into  the  gall-bladder  ;  tampon  down  to  the  gall- 
bladder, fixation  sutures.      Dressing. 

Course. — Bile  flows  constantly,  the  temperature  always  re- 
mains in  normal  limits.  On  the  24.  8.  the  first  change  of 
dressing  was  made  ;  the  sutured  wound  was  healed  p.  p.  ;  the 
sutures  were  removed,  the  tube,  which  had  become  very  thin 
walled  from  long  boiling,  was  taken  out.  One  could  not  again 
succeed  in  entering  the  gall-bladder,  therefore  a  tampon  was  in- 
troduced down  to  the  opening.      On  the  next  dressing,  27.  8.,  no 


CLINICAL  AND  OPERATION  HISTORIES. 


177 


bile  on  dressing.  One  easily  enters  the  gall-bladder  and  detects 
with  a  probe  a  stone  in  the  neck  of  the  bladder  ;  it  cannot  be 
removed.  Tube  in  gall-bladder.  Dressing.  No  flow  of  bile. 
31.  8.  change  of  dressing,  stone   in   fragments   removed  in  part. 

4.  9.,  remainder  of  the  stone  removed;  abundant  flow  of  bile  ;  since, 
frequent  dressings  on  account  of  the  soaking  of  bile.  Tube  left 
out  10.  9.  Discharged  to  her  home  free  from  distress  on  17.  9. 
98,  with  a  still  secreting  biliary  fistula.  Patient  is  to  be  dressed 
at  home.      Presents  herself  in  December  cured. 

(b)  Mrs.  B.,  27  years,  sergeant's  wife,  from  Halberstadt.  P^n- 
tered,  7.  5.  96.      Oper.,  9.  5.  9^    Cystostomy.     Discharged,  23. 

5.  96.  Cured,  15.  7.  96.  I^itjent  mother  of  a  healthy  child,  is 
said  to  come  from  a  healthy  fa2iiily,  and  herself  to  have  always 
been  healthy.  Her  present  di^ess,  which  consists  of  stomach 
cramps,  vomiting  and  constipation,  began  about  2  years  ago. 
A  feeling  of  fullness  was  almdjt  always  present,  so  that  she  was 
often  obliged  to  loosen  thoMfls^  of  her  jacket.  Jaundice  has 
never  appeared.  The  lastgjitack  was  on  the  5th  of  May;  since 
then  there  exists  constant  intense  pains  in  the  region  of  the  gall- 
bladder. Stools  and  urine  are  said  to  have  been  of  normal 
color.      Fever  has  never  exist^.   . 

Status  Praesens. — Small, ^dsifcately  built  woman  in  a  pretty 
good  condition  of  nutrition.  No  jaundice.  Heart  and  lungs 
normal.  Region  of  the  gall-«y&rider  very  sensitive  to  pressure  ; 
otherwise  nothing  to  be  felt.  JThe  spleen  is  distinctly  enlarged 
and  palpable  ;  fever  does  not  ^xist.  The  pulse  is  strong,  regu- 
lar, 75  to  the  minute.  Stools  mre  brown,  urine  free  from  albumin 
and  sugar.  -^  V 

Diagnosis. — Acute  chqteej^a^itis. 

Operation  on  the  9.  5>i96,/at  4.30  p.m.  Morphine-atropine- 
chloroform  anaesthesia.  Longitudinal  incision  in  the  right  rectus 
abdom.  muscle.  On  opening  the  belly  it  was  apparent  that  the 
tensely  distended  gall-bladder  lay  high  up  under  the  curvature 
of  the  ribs  ;  no  adhesions  ;  protection  of  the  belly  by  introduc- 
tion of  compresses.  Puncture  of  the  gall-bladder.  In  this 
15 


1^8  GALLSTONE  DISEASE. 

manner  about  150  ccm.  of  slimy  fluid  was  removed.  The  punc- 
ture was  enlarged  ;  1 5  stones  of  different  sizes  (2  of  hazelnut 
size)  in  the  gall-bladder.  The  cystic  duct  also  is  obstructed  by 
a  stone  ;  this  stone  could  be  pushed  into  the  gall-bladder  and 
was  thence  removed.      Cure. 

///  this  case  the  "  cramps  of  the  stomach  "  and  the  sensitiveuess 
to  pressure  in  tJie  region  of  tlie  gall-bladder  pointed  to  gallstones. 
Fever  was  not  detected,  the  liver  was  not  enlarged,  a  tumor  of  the 
gall-bladder  was  not  to  be  felt,  jaundice  did  not  exist.  Even  tJien 
ivJien  the  belly  ivas  opened,  it  was  difficult  to  find  the  enlarged 
and  far  backward  sunken  gall-bladder,  not  to  mention  seeing  it. 
And  yet  the  operation,  by  reason  of  the  size  of  the  stones  and 
the  severe  inflammation,  was  the  only  correct  procedure. 

(c)  P.,  36  years,  saddler,  from  Oschersleben.  Entered,  26.  4. 
97.  Operation,  28.  4.  97.  Cystostomy.  Discharged,  26.  5. 
97.      Cured  (6.  6.  97). 

Patient,  the  father  of  two  healthy  children,  is  said  to  have 
always  been  healthy  until  3  years  ago.  At  this  time  he  had 
pains  in  the  stomach,  which  sometimes  increased  to  cramps  of 
stomach.  V^omiting  also  occurred  from  time  to  time.  Stools 
were  always  regular.  Typical  colic  attacks  of  variable  duration 
occurred  and  recurred  at  irregular  intervals  (6  weeks  to  y. 
year  intervals).  Jaundice  has  never  appeared  in  the  three  years. 
As  a  young  man  of  18  years  he  suffered  from  duodenal  catarrh, 
complicated  with  jaundice.  On  24th  of  April,  '97,  a  sudden 
change  for  the  worse  occurred  ;  the  pains  in  the  gall-bladder 
were  so  violent,  that  the  patient  immediately  determined  to  be 
operated  upon. 

Status  Prsesens. — Powerfully  built  man,  very  well  developed 
layer  of  fat.  No  jaundice.  Heart  and  lungs  normal.  Liv^er  and 
spleen  not  enlarged.  In  the  region  of  the  gall-bladder  a  resist- 
ance, but  no  actual  tumor  to  be  felt.  At  that  point  extraordinary 
sensitiveness  to  pressure.  No  fever.  Pulse  84,  regular,  strong. 
Urine  contains  no  abnormal  constituents.    The  stools  are  brown. 

Diagnosis. — Acute  cholecystitis  in  a  chronicalh-  inflamed 
gall-bladder  ;  cystic  duct  probably  closed  by  stones. 


CLINICAL  AND  OPERATION  HISTORIES.  1 79 

Operation  on  the  28.  4.  97.  Chloroform  ancnesthcsia.  Longi- 
tudinal incision  in  right  rectus  abdominal  muscle  from  curvature 
of  the  ribs  downward.  On  opening  the  belly  there  appeared  a 
tensely  distended  gall-bladder  adherent  to  the  omentum  and  in- 
testine. The  adhesions  were  separated.  The  surroundings  of 
the  gall-bladder  were  protected  all  around  with  sewed  napkins  ; 
then  followed  the  puncture  of  the  gall-bladder,  by  which  about 
50ccm.  of  sero-purulent  fluid  was  removed.  The  later  examina- 
tion of  this  fluid  showed  it  to  contain  the  bacterium  coli.  In  the 
gall-bladder  and  cystic  duct  two  stones.  It  was  possible  to 
push  the  stones  into  the  gall-bladder  and  thence  to  remove  them  ; 
they  were  about  the  size  of  hazelnuts.  Cystostomy.  Duration 
of  the  operation,  i  ^^  hours.  Wound  course  normal  ;  on  second 
day  after  operation  bile  flowed.  Patient  always  free  from  fever. 
On  26.  5.  the  patient  is  discharged  with  a  slightly  secreting  biliary 
fistula.     The  fistula  closed  6.  6.  97.      Later  glowing  health. 

Remarks. — That  the  duodenal  catarrah  with  jaundice  may 
have  given  rise  to  the  gallstones  is  very  likely  possible.  The 
patient  had  already  often  had  inflammatory  processes  in  the  gall- 
bladder ;  now  the  colics  had  become  unendurable  so  that  the 
patient  voluntarily  sought  the  clinic.  The  tumor  was  not  to  be 
felt ;  the  very  painful  resistance  indicated  an  acute  cholecystitis. 
Jaundice  and  fever  were  wanting. 

If  one  finds  in  a  patient,  who  has  often  had  colics,  the  region 
of  the  gall-bladder  more  resistant  than  the  corresponding  place 
on  the  other  side  of  the  abdomen,  if  he  complains  on  pressure 
of  very  severe  pains  radiating  to  the  stomach  or  back,  then  one 
may  make  the  diagnosis  acute  serous  cholecystitis — perhaps  also 
already  purulent.  Jaundice  is  wanting,  since  the  disease  is  local- 
ized in  the  gall-bladder  ;  the  choledochus  is  not  involved  in  the 
disease,  and  the  fever  is  slight  with  slight  infection,  and  when 
the  peritoneal  surface  of  the  gall-bladder  does  not  participate, 
indeed  it  is  usually  absent. 

(d)  Mrs.  M.  Th.,  46  years,  wife  of  a  merchant,  from  Madge- 
burg.      Entered,  19.  9.  98.     Operation,  20.  9.  98.     Cystostomy. 


l8o  GALLSTONE  DISEASE. 

Discharged,  ij.  lO.  98,  with  biliary  fistula.  This  closed  in  the 
beginning  of  February. 

Amnesis. — Two  brothers  died  of  heart  disease.  On  24.  i. 
97  the  patient,  who  had  never  before  been  actually  ill,  suddenly 
without  demonstrable  cause  was  seized  with  boring,  cramp-like 
pains,  in  the  region  of  the  liver,  which  radiated  toward  the 
back  ;  with  this,  great  weakness,  cold  sweat,  profuse  vomiting. 
No  jaundice,  no  fever.  After  morphine,  diminution  of  the  pains. 
Similar  attacks  recurred  subsequently  about  every  14  days  in 
varying  intensity.  April,  1897,  at  home  the  patient  carried  out 
a  Carlsbad  cure.  Thereafter  the  attacks  appeared  at  longer  in- 
tervals (about  every  4  weeks).  From  15.  5. -15.  6.  98,  cure  in 
Carlsbad,  there  2  slight  attacks.  After  the  return  numerous  at- 
tacks of  considerable  violence  at  about  ten-day  intervals.  On 
2.  9.  98  an  extremely  painful  attack,  which  lasted  almost  a  week 
and  was  attended  by  fever.  Last  attack  on  16.  9.  98.  From 
then  till  now  feeling  well.  Jaundice,  discoloration  of  stools, 
brown  color  of  the  urine  are  said  never  to  have  been  present. 
Never  expulsion  of  stones.  Dr.  Siedentopf  of  Magdeburg  and 
Dr.  Pleschner  of  Carlsbad  earnestly  advised  operation. 

Status  Praesens. — Powerful  woman  with  thick  layer  of  fat. 
Liver  not  enlarged.  Region  of  gall-bladder  only  slightly  sen- 
sitive to  pressure,  gall-bladder  not  palpable.  Abdomen  every- 
where soft,  besides  nowhere  painful.  Stools  brown.  Urine 
free  from  albumin,  sugar  and  biliary  coloring  matters.  No 
fever,  no  jaundice.  Pulse  strong,  regular,  80  ;  moderately  large 
umbilical  hernia. 

Diagnosis  on  the  ground  of  the  present  examination  impos- 
sible ;  according  to  the  amnesis  obstruction  of  the  cysticus  until 
a  few  days  ago  ;  formerly  cholecystitis,  probably  at  present  stones 
in  the  gall-bladder.  Mrst  under  anaesthesia,  which  was  induced 
for  the  purpose  of  operation,  one  felt  clearly  in  the  region  of 
the  gall-bladder  an  apple-sized  tumor,  which  passes  broadly  into 
the  liver. 

Operation.  -Chloroform  anaesthesia.  Longitudinal  incision 
in   right   rectus   abdominal   muscle   from    curxature  of  the  ribs 


CLINICAL  AND  OPERATION  HISTORIES.  l8l 

downwards.  The  gall-bladder  reaches  three  finger-breadths  be- 
low the  lower  liver  border,  is  slightly  distended,  adherent  to  the 
transverse  colon  and  omentum  by  flat,  easily  separable  adhe- 
sions. The  walls  of  the  gall-bladder  are  thickened  and  inflamed. 
Upon  the  gall-bladder  a  thin  drawn-out  lobe  of  liver  substance. 
Puncture  of  the  gall-bladder,  removal  of  60  ccm.  of  dark -brown 
bilious  fluid.  Enlargement  of  the  puncture  by  incision.  In  the 
gall-bladder  neck  three  hazelnut-sized,  dark-brown,  roundish 
stones,  which  lie  very  firm  and  deep,  and  are  removed  only  with 
the  greatest  care.  A  pea-sized  stone  in  the  gall-bladder.  Still 
more  difficult  was  the  removal  of  a  fourth  similar  sized  stone 
lying  quite  fast  in  the  beginning  of  the  cystic  duct ;  it  was,  how- 
ever, possible  to  push  it  into  the  gall-bladder  and  remove  it  by 
a  dressing  forceps.  Immediately  clear  bile  escapes.  Chole- 
dochus  and  hepaticus  patent.  Attachment  of  the  gall-bladder 
to  the  parietal  peritoneum.  Drainage  by  tube.  Closure  of  the 
abdominal  wound  by  layer  suture.      Duration,  one  hour. 

Course. — Afebrile,  with  good  general  condition.  Profuse 
escape  of  bile.  First  change  of  dressings  4.  10.  98,  removal  of 
tube  and  sutures.  Subsequently  about  every  day  dressings 
changed.  Escape  of  bile  from  the  fistula  had  very  quickly 
diminished,  and  at  present  (13.  10.)  is  very  slight.  General  con- 
dition continues  good,  no  distress.  Glowing  health  ;  discharge 
on  27.  10.  follows. 

Closure  of  fistula  results  in  beginning  of  December.  Patient 
feels  extraordinarily  well.  In  January  the  fistula  again  broke 
open,  yet  the  escape  of  bile  was  very  small.  I  have  not  the 
slightest  anxiety  but  that  soon  definitive  cure  will  occur.  This 
occurs  in  beginning  of  February. 

Remarks. — It  is  certain  that  in  this  case  we  had  to  do  with  an 
acute  cholecystitis,  which  on  16.  9.  98  suddenly  abated.  As 
evidences  of  the  inflammation  set  up  by  obstruction  of  the  chole- 
dochus  we  found  at  the  operation  still  the  discoloration  of  the 
bile,  the  inflammatory  thickening  of  the  walls  of  the  gall-bladder. 
The  attack  of  colic  was  relieved  by  the  abatement  of  the  swelling 


I  82  GALLSTONE  DISEASE. 

of  the  mucous  membrane  of  the  cystic  duct,  the  bile  could  again 
flow  in  and  out,  the  inflammatory  secretion  left  the  gall-bladder 
through  the  cystic  and  common  ducts,  and  reached  the  intestine  ; 
these  are  the  cases  in  which  Carlsbad  cures  are  so  famous,  yet  it 
is  still  questionable  whether  the  inflammation  is  actually  relieved 
by  the  use  of  the  hot  Sprudel.  I  personally  regard  it  as  possible. 
Here,  moreover,  the  flooding  of  the  biliary  system  with  the 
exudate  from  the  gall-bladder  made  no  impression  upon  the 
general  condition.  The  cases  heretofore  reported  are  more  or 
less  typical  of  the  acute  sero-purulent  cholecystitis.  In  the  fol- 
lowing we  learn  to  recognize  sequelae  of  cholecystitis,  perichole- 
cystitis and  circK inscribed  and  diffuse  peritonitis.  In  conclusion, 
I  report  a  few  clinical  histories  which  show  how  easily  one  may 
confound  cholecystitis  with  epityphlitis  (appendicitis). 

We  learn  by  the  following  clinical  history  to  recognize  a  case 
of  severe  cholecystitis  with  circuniscribed  peritonitis  (perichole- 
cystitis exudativa). 

Mrs.  M..  56  years,  wife  of  pastor,  from  Quedlinburg,  entered 
19.  5.  97.  Operation,  31.5.  97.  Cystostomy.  Discharged  by  re- 
quest, 22.  7.  97.  Cured,  i.  9.  97.  Patient  the  mother  of  five 
healthy  children,  is  sent  by  Dr.  Sanitary  Councillor  Ihlefeld  to 
the  clinic.  She  is  said  to  have  been  always  healthy  until  eight 
years  ago.  About  this  time  she  was  taken  with  pains  in  the 
stomach,  vomiting  and  constipation.  The  region  of  the  gall- 
bladder was  very  sensitive  to  pressure.  Typical  attacks  of  colic, 
but  all  without  jaundice  ;  has  been  obliged  to  endure  twelve  of 
them  ;  they  were  of  different  duration,  half  hour  to  two  days. 
Since  Christmas  '96  she  has  observ^ed  a  tumor  in  the  right  hy- 
pochondrium,  which  was  very  painful.  Since  in  spite  of  the 
employment  of  the  most  different  remedies  the  pain  would  not 
abate,  Mrs.  M.  determined  to  be  operated  upon.  Any  sort  of 
an  abnormality  in  the  character  of  the  stools  or  urine  has  not 
been  observed  by  the  patient  ;  in  the  last  ten  days  there  has 
been  high  fever. 

Status  Prsesens. — Large,  powerfully-built  woman  of  moder- 
ately  good  condition  of  nutrition.      No  jaundice.      Heart  and 


CLINICAL  AND  OPERATION  HISTORIES.  18.5 

lungs  normal.  In  the  gall-bladder  region  is  to  be  felt  an  egg- 
shaped  tumor  with  smooth  surface,  and  of  firm,  elastic  consist- 
ence. The  tumor  moves  with  the  respiration,  and  passes  into 
the  liver  dullness  ;  its  lower  border  is  two  finger-breadths  under 
the  navel.  No  enlargement  of  the  spleen.  Stools  brown. 
Urine  clear  yellow,  contains  no  abnormal  constituents.  Temp., 
evening,  39.1°.      Pulse  94,  strong  and  regular. 

Diagnosis. — Acute  cholecystitis,  probably  already  purulent, 
cystic  duct  stone. 

Operation  on  31.  5.  97.  Choloroform  anaesthesia.  Longi- 
tudinal incision  in  the  right  rectus  abdominal  muscle  from  curva- 
ture of  the  ribs  to  the  navel.  The  abdomen  was  opened,  there 
presented  the  large  gall-bladder  whose  upper  surface  was  covered 
with  peritonitic  fibrinous  layers  ;  likewise  the  parietal  peritoneum 
in  the  neighborhood  of  the  gall-bladder  is  markedly  injected, 
thickened  and  covered  with  fibrin.  From  the  gall-bladder  broad 
adhesions  extend  to  the  transverse  colon  and  the  omentum. 
After  these  are  separated  the  gall-bladder  is  punctured,  and  in 
so  doing  100  ccm.  of  pus  let  out.  The  puncture  is  enlarged  by 
incision,  the  gall-bladder  dried  out  with  strips  of  gauze,  sus- 
pended, and  now  we  proceeded  to  the  palpation  of  the  large  bile 
ducts.  In  the  cystic  duct  one  feels  two  hazelnut-sized  stones  ; 
it  is  possible  to  shove  them  into  the  gall-bladder  and  thence  to 
remove  them  ;  immediate  flow  of  bile.  Hepatic  and  common 
ducts  are  free  from  stones.  On  account  of  the  circumscribed 
peritonitis  and  the  suppuration  in  the  gall-bladder  the  latter  was 
only  partially  sewed  to  the  parietal  peritoneum.  In  the  depths 
toward  the  under  surface  of  the  gall-bladder  a  tampon  was  in- 
troduced. Afterwards  partial  closure  of  the  abdominal  wound. 
Dressing.  Duration,  one  hour.  Wound  course  was  absolutely 
normal  ;  on  3d  day  bile  flowed  in  abundant  quantity.  Daily 
change  of  dressing.  Patient  on  request  was  discharged  on  22. 
7.  The  biliary  fistula  closed  very  much  later,  on  i.  9.  At 
present  Mrs.  M.  is  completely  free  from  distress,  and  enjoys 
good  health. 

We  had  in  the  following  case  to  do  with  diffuse  purulent  peri- 


1 84  GALLSTONE  DLSEASE. 

tonitis  followin^:^  cholecystitis  purulcnta  without  perforation  or 
stone. 

Mrs.  E.  G.,  31  years,  wife  of  a  laborer,  from  Pabstorf.  En- 
tered, 2.  12.  97.  Open,  2.  12.  97.  Cystectomy.  Discharged, 
15.  I.  98.      Cured. 

Amnesis.  —  Mother  yet  Hving  in  good  health  ;  of  brothers  and 
sisters,  8  are  still  living  and  healthy.  Mrs.  G.  had  as  a  child 
diseased  glands  (father  probably  tuberculosis),  married  at  25 
years,  mother  of  3  children,  the  eldest  scrofulous.  Since  the 
end  of  1896  the  patient  has  had  pains  in  the  pit  of  the  stomach 
which  made  themselves  noticeable  at  times  as  pressure.  Appe- 
tite undisturbed,  constipation  for  a  couple  of  years.  November, 
1 897,  patient  noticed  increasing  pain  in  the  riglrt  side  (region  of 
the  gall-bladder)  ;  there  appeared  a  painful  lump  under  the  right 
border  of  the  ribs  ;  one  day — about  8  days  from  the  beginning — 
the  patient  spent  in  bed.  The  appetite  had  now  disappeared  ; 
much  thirst.  Patient  does  not  know  whether  she  had  fever. 
The  physician.  Dr.  Klavehn,  ordered  after  an  examination  the 
transfer  to  the  clinic,  and  was  present  at  the  operation.  Patient 
arrives  toward  evening,  2.  12.  97. 

Status  Prsesens. — Small,  thin  woman  ;  old  cicatrix  on  right 
side  of  neck.  Belly  somewhat  distended  ;  tympanites  ;  in  the 
gall-bladder  region  evident  resistance  ;  tumor  palpable  almost  to 
the  level  of  the  navel ;  oedema  of  the  abdominal  walls  on  the 
right  side  above  ;  flatus  does  not  pass.  Temperature  40.8". 
Pulse  130,  small. 

Diagnosis. — Empyema  of  the  gall-bladder,  pericholecystitis, 
diffuse  purulent  peritonitis. 

Operation  in  evening  at  half-past  nine  o'clock.  Chloroform 
anaesthesia.  Longitudinal  incision  in  the  right  rectus  abdominal 
muscle.  There  presents  as  a  pretty  large  tumor  the  gall-blad- 
der which  is  adherent  to  the  omentum.  The  wall  is  covered 
with  pus,  and  likewise  the  visible  intestinal  convolutions.  In 
the  abdominal  cavity  considerable  muddy  fluid.  Extirpation  of 
the  gall-bladder  which   contains  pus,  but  no  stones.      Extensive 


CLINICAL  AND  OPERATION  HISTORIES. 


185 


tamponade  of  the  cavity  of  the  belly.  Partial  closure  of  the 
abdominal  wound.  Normal  salt  infusion  from  4.  12.  evening  up 
till  II.  12.  Daily  twice  i}^  liter  normal  salt  solution  subcu- 
taneously.  In  course  a  paralysis  of  the  bladder  required  cathe- 
terization with  washing  out  of  bladder.  Cure.  Temperature 
before  operation,  40.8°. 


Temperature. 

5- 

39-1 

40. 

12 

38 

5 

38.9 

4- 

38.5 

38.5 

13 

3^ 

5 

38.5 

37-9 

38.7 

14 

37 

8 

38. 

6. 

38.2 

38.7 

15 

37 

38.4 

7- 

37^8 

38.5 

16 

37 

5 

37.9 

8. 

38.5 

39-5 

17 

37 

2 

37-5 

9- 

38-3 

39-5 

18 

37 

3 

37-4 

10. 

38.6 

39-5 

19 

37 

3 

37-3 

1 1. 

39- 

38.9 

20 

37 

2 

37-7 

Later,  normal  temperature.      Discharged  cured  on  15.  I.  98. 

The  diffuse  purulent  peritonitis  came  slowly  to  a  cure.  Here 
also  the  subcutaneous  infusions  of  normal  salt  solution  proved 
their  value. 

Cholecystitis  now  and  then  runs  its  course  with  symptoms  of 
ileus,  especially  then,  if  adlicsioiis  Jiavc  taken  place  bctivecn  in- 
testine, omentum  and  gall-bladder,  but  also  witJioiit  such  a  previous 
adhesive  peritonitis  can  ileus-like  trouble  occur,  as  the  following 
case  shows  : 

Dr.  W.,  44  years,  from  Wilna.  Entered,  12.  10.  98.  Open, 
16.  10.  98.  Cystostomy  in  two  stages.  Discharged,  i.  12.  98. 
Cured. 

Amnesis. — Patient  had  as  a  student  apex  catarrh  of  lungs, 
as  a  young  physician  a  left-sided  exudative  pleurisy  ;  both  are 
cured.  About  six  years  ago  the  patient  had,  after  some  heavy 
fatty  foods,  cramp-like  pains  in  the  region  of  the  stomach,  which 
radiated  to  the  back,  rarely  were  attended  by  slight  vomiting, 
and  were  interpreted  by  him  as  proceeding  from  a  catarrh  of  the 
stomach.  Not  long  afterwards,  about  5  ^  years  ago,  suddenly 
16 


1 86  GALLSTONE  DISEASE. 

there  occurred  without  perceivable  reason  a  typical  gallstone 
attack,  which  developed  with  ileus-like  symptoms  so  that  lapar- 
otomy was  entertained.  Violent,  cramp-like  pains  in  the  region 
of  the  liver,  profuse  vomiting,  with  it  distended  belly,  and  3 
days'  constipation  ;  in  addition  jaundice,  which  lasted  2  weeks, 
much  biliary  coloring  matter  in  urine,  great  prostration.  Patient 
kept  his  bed  5  or  6  weeks,  then  went  to  Carlsbad.  After  the 
Carlsbad  cure  for  a  time  good  health  ;  then  occurred  again,  after 
errors  of  diet,  mild  colics.  In  the  following  spring  again  an 
attack  as  violent  as  the  first.  Patient  again  seeks  relief  in  Carls- 
bad. Two  months  after  his  return  from  there  renewed  violent 
attack,  with  jaundice,  fever,  etc.  Subsequently  there  now  oc- 
curred, at  greater  or  less  intervals,  attacks  which  vary  in  their 
intensity,  some  with,  some  without  jaundice,  most  with  slight 
elevation  of  temperature.  Patient  still  again  seeks  Carlsbad, 
and  there  each  time  finds  relief,  and  is  several  months  after  the 
cure  free  from  distress.  In  the  spring  of  1898,  during  a  stay  in 
Carlsbad,  an  extremely  violent  attack  occurred  ;  with  it  there 
was  a  great  deal  of  biliary  coloring  matter  in  the  urine,  but  skin 
jaundice  was  very  slight.  In  the  following  months  the  patient 
lost  weight  very  greatly,  complained  almost  constantly  of  a  dull, 
boring  pain  in  the  region  of  the  gall-bladder  which  made  him 
very  nervous  and  limited  his  working  power  and  ability  to  do. 
Last  July  a  very  severe  attack  overcame  him  ;  it  began  with  i  ^- 
hour  long  chill,  the  temperature  reached  to  40°,  remained  as 
high  3  days  ;  jaundice  and  all  the  other  symptoms  of  the  typical 
colic  attack  were  present.  After  two  weeks'  rest  in  bed  the 
patient  was  able  to  again  get  up,  but  felt  constantly  weak,  dis- 
posed to  fall,  with  disgust  for  work  ;  despite  most  careful  diet 
there  plagued  him  constantly  dull,  boring  pains  in  the  region  of 
the  gall-bladder.  Stones  had  not  been  sought  during  his  ill- 
ness.     Passage  of  them  was  never  observed. 

Status  Prsesens. — Spare,  pale  man.  Some  arterio  sclerosis. 
Urine  free  from  albumin,  sugar  and  biliary  coloring  matters. 
Heart  and  lungs  normal.     In  region  of  the  gall-bladder  slight 


CLINICAL  AND  OPERATION  HISTORIES.  1 8/ 

resistance.  No  tumor,  no  enlargement  of  the  liver.  Tempera- 
ture normal. 

The  diagnosis  was  made  of  shrunken  gall-bladder  with  stones. 
Adhesions. 

Operation,  i6.  10.98.  Duration,  5/j^  hour.  No  good  chloro- 
form anctsthesia.  Longitudinal  incision  in  right  rectus  abdom. 
muscle.  Gall-bladder  small,  shrunken,  some  adhesions  with  the 
transverse  colon,  easy  separation.  Cystic  duct  free  ;  here  a  swollen 
gland  is  to  be  felt.  Excision  on  account  of  the  deep  situation  and 
bad  anaesthesia  impossible,  likewise  cystostomy.  The  parts  of 
the  lower  liver  border  lying  either  side  of  the  gall-bladder  were 
carefully  sutured  to  the  parietal  peritoneum  so  as  to  make  accessi- 
ble for  further  procedures  the  unopened  gall-bladder,  which  con- 
tained 2  large  stones.  Then  tamponade  with  sterile  gauze  along 
the  gall-bladder.  Closure  of  the  remainder  of  the  abdominal 
wound.  After  the  anaesthesia,  in  the  first  24  hours,  much 
vomiting  of  brownish  masses  (blood).  No  fever,  pulse  80,  good 
and  strong.  Evening,  38°  C.  in  ano  ;  pulse,  80.  Vomiting  re- 
peated so  frequently,  that  a  washing  out  of  the  stomach  was 
done  with  a  2  per  cent.  sol.  of  soda,  with  a  subsequent  washing 
with  I -1 000  sol.  of  silver  nitrate.  In  addition  nutrient  enemata 
with  the  addition  of  secale  cornutum  0.5.  We  have  not  infre- 
quently seen  these  disturbances  of  the  circulation  of  the  portal 
system  after  operations  upon  the  liver  and  bile  system.  We  at 
first  believed  that  the  cause  was  to  be  imputed  to  the  tampon 
upon  the  choledochus  and  vena  porta.  Yet  we  saw  it  in  cases  in 
which  a  tampon  was  not  employed.  Has  it  anything  to  do  with 
the  chloroform  ?  Nowhere  do  we  find  statements  concerning  it, 
so  that  we  earnestly  desire  from  others  the  explanation  of  it. 
In  many  cases  it  passed  by  without  producing  any  evil  effect ;  in 
many  it  led  to  death.  The  patients  have  no  fever,  yet  the  pulse 
becomes  rapid,  small  and  accelerates.  Peritonitis  in  no  case  was 
demonstrable.  The  cases  in  which  the  pulse  remains  strong  are 
of  good  prognosis.  Therapeutically  we  employ  :  washing  out 
with  soda  solutions,  abstinence  from  food  and  drink,  subcutane- 


1 88  GALLSTONE  DISEASE. 

ous  normal  salt  solutions.  Enemata  with  ergot  (3  times  a  day, 
0.5-1.0).  Since  the  soda  solutions  again  dissolve  the  coagula, 
we  afterwards,  to  encourage  coagulation,  repeat  twice  the  wash- 
ing with  a  I  per  M.  sol.  of  silver  nitrate.  An  outwashing  with 
ice  water  follows  this.  This  ominous  vomiting  of  blood  we  have 
also  once  observed  after  a  radical  operation  for  hernia  according 
to  Bassini ;  for  the  most  part  it  concerns  men.  Is  it  alcohol, 
chloroform  or  arterio  sclerosis  which  in  it  plays  the  leading 
role  ?  Von  Eiselsberg  has  spoken  of  this  blood-vomiting  at  the 
Surgical  Congress  of  this  year,  and  ascribes  it  to  the  separation 
of  omental  bands  :  in  half  of  my  cases  there  were  no  ligations 
of  the  omentum. 

The  vomiting  of  blood  lasted  about  3  days,  and  then  let  up 
after  frequent  outwashing  of  the  stomach  with  ice  water.  The 
patient  had  then  to  suffer  very  much  from  cough,  in  consequence 
of  which  the  wound  pained  him.  Otherwise  the  subsequent 
course  was  afebrile.  Ten  days  after  the  operation,  after  remov- 
ing the  tampon,  the  gall-bladder  was  opened  with  the  knife  and 
pus  let  out.  One  stone  about  the  size  of  a  cherry  was  removed 
with  the  forceps,  a  second  lay  much  deeper.  The  second  stone 
could  first  be  seized  after  the  median  wall  of  the  gall-bladder 
had  been  divided  with  a  blunt-pointed  knife.  A  stone  the  size 
of  a  hazelnut  was  removed.  Then  bile  escaped  in  considerable 
quantity.  On  the  5.  1 1.  98  the  patient  got  up  for  the  first  time, 
with  a  broad  strap  of  adhesive  plaster  around  the  belly.  Appe- 
tite and  stools  regular,  cough  has  abated.  Constant  normal 
temperature.  On  i .  1 1 .  is  discharged  to  his  home  with  almost 
healed  wound. 

In  the  following  case  we  likezvise  have  to  do  zvitJi  ileus-like 
symptoms  ;  zvhether  a  cholecystitis  or  appendicitis  was  present  was 
very  difficult  to  decide  beforehand.  The  principal  pains  the 
patient  had  in  the  region  of  the  gall-bladder. 

F.  K.,  38  years,  laborer,  from  Quedlinburg.  Entered,  2.  11. 
97.  Operation,  2.  11.  97  (evening).  Ectomy.  Resection  of 
appendix.      Discharged,  9.  i.  98.      Cured. 


CLINICAL  AND  OPERATION  HISTORIES.  1 89 

Amnesis. — Patient,  heretofore  healthy,  fell  suddenly  ill  on  i. 
6.  97  in  morning.  Disease  began  with  pain  in  the  stomach. 
Patient,  however,  went  to  work,  but  was  obliged  about  half-past 
four  o'clock  to  go  home.  The  physician  ordered  in  the  evening, 
about  7  o'clock,  a  powder  ;  thereafter  vomiting,  no  movement  of 
the  bowels,  no  hurt,  marked  nausea,  during  the  whole  night 
vomiting.  The  physician  on  2.  11.  in  morning  declared  an  ob- 
struction of  the  bowels.  Vomiting  in  fact  ceased,  but  neither 
flatus  nor  stool  followed. 

Status  Prsesens. — Medium-sized,  delicate  man.  Urine  nor- 
mal, small  in  quantity.  Heart  and  lungs  normal.  Belly  not  dis- 
tended, very  tender  in  region  of  the  navel  and  on  right  side  above. 

Diagnosis. — Ileus  ex  appendicite  gangrenous  (?)  cholecystitis. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision 
in  the  middle  hne,  and  in  addition  horizontal  incision  to  the  right. 
One  comes  upon  adhesions  which  unite  the  transverse  and  as- 
cending colon.  After  separation  of  these  there  presents  the. 
serpentine  appendix,  which  is  thickened  for  a  considerable  dis- 
tance, and  which  ascends  on  the  external  and  posterior  wall  of 
the  ascending  colon  and  is  adherent  to  it.  This  is  separated  and 
removed.  The  stump  double  sutured.  The  gall-bladder,  con- 
cealed under  the  liver,  which  is  entirely  enveloped  in  adhesions, 
permits  itself  to  be  enucleated  from  these  like  an  egg  from  its 
shell,  and  is  extirpated,  the  cystic  artery  is  tied,  the  stump  over- 
cast. Afterward  the  closure  of  the  abdominal  wound  with 
through  and  through  sutures  from  within  out,  gauze  down  to 
the  stump  of  the  appendix,  and  the  stump  of  the  cystic  duct  or 
liver  bed  is  brought  out  the  angle  of  the  wound.  Afebrile 
course  38.6°— 38.7°.  On  the  change  of  dressings  on  the  9.  11. 
stinking  gauze  is  removed  ;  the  infected  abdominal  wound  on  re- 
moving the  sutures  spreads  apart  save  the  peritoneum,  which 
holds.  Fresh  gauze  is  introduced.  Dressing.  Similar  dress- 
ing on  the  10.  II.  97.  The  broad  granulating  surface  of  the 
abdominal  wound  is  grafted  on  the  14.  12.  97.  Good  healing. 
Discharged  9.  i.  98  with  abdominal  bandage. 


190  GALLSTONE  DISEASE. 

A  coiifiisioii  of  cholecystitis  witJi  appendicitis  was  observed  in 
the  following  case  : 

Mrs.  R.,  42  years,  from  Neinstedt.  Entered,  6.  5.  98.  Oper., 
8.  5.  98.      Cystostomy.      Discharged,  28.  5.  98.      Cured. 

Amnesis. — Parents  dead,  two  brothers  are  living  and  healthy. 
Patient  married  at  35  years  of  age,  and  is  the  mother  of  a  healthy 
child.  Fifteen  years  ago  the  patient  fell  ill,  according  to  her 
statement,  with  an  inflammation  of  the  appendix,  which  first 
passed  off  after  about  3  months.  Since  then  she  often  has  pain 
in  the  belly  and  constipation.  In  the  middle  of  April,  1898, 
the  patient  fell  ill  with  pain  in  the  pit  of  the  stomach,  which 
made  itself  evident  especially  after  eating  ;  in  addition  to  this 
there  were  pains  in  the  back,  which  in  the  interval,  however, 
have  disappeared.  Now  there  exists,  with  fever  up  to  38.8° 
since  4  days,  pains  in  the  right  side  of  the  abdomen.  Dr.  Stein- 
briick,  of  Ouedlinburg,  proposes  operation. 

Status  Praesens. — ]\Iedium-sized,  well-nourished  woman,  with 
normal  organs,  except  that  the  lower  border  of  the  liver  it  at 
the  level  of  the  navel  in  the  right  mammary  line,  beneath  there 
is  a  sensitive  tumor.  The  attending  physician  had  imagined  an 
appendicitis  ;  on  closer  examination  under  anaesthesia  it  was  evi- 
dent that  an  acute  cholecystitis  was  before  us.  Moreover,  the 
gall-bladder  was  further  to  the  right  and  below  than  normal, 
therefore  the  confusion.      No  sensitiveness  in  appendix. 

Operation  on  8.  5.  Choloroform  anaesthesia.  Longitudinal 
incision  in  the  right  rectus  abdominal  muscle  from  the  curvature 
of  the  ribs  to  beneath  the  navel.  One  finds  the  liver  at  the 
level  of  the  navel  ;  the  gall-bladder,  w^hose  wall  is  thickened, 
contains  a  large  concretion  ;  there  exist  adhesions  with  omen- 
tum, colon  and  stomach.  These  are  separated,  the  gall-bladder 
after  the  aspiration  of  muddy  bile  opened,  and  a  hazelnut-sized 
stone  removed,  the  bladder  attached  to  the  parietal  peritoneum, 
tamponade  of  the  under  surface  of  the  gall-bladder.  Gauze 
brought  out  the  wound  angle.  Through  and  through  inter- 
rupted suture  of  the  abdominal  wound.  Immediate  escape  of 
bile.      Everything  normal  in  the  appendix. 


CLINICAL  AND  OPERATION  HISTORIES.  I9I 

Course  undisturbed  by  elevation  of  temperature.  Constant 
flow  of  bile.  The  first  change  of  dressings  on  the  16.  5.  shows 
that  the  wound  is  healed  per  primam  ;  the  sutures  are  removed. 
Already  by  the  26.  5.  the  fistula  is  almost  healed,  and  Mrs.  R.  can 
therefore  be  discharged  for  her  home  on  the  28.  5.  with  a  small 
streak  of  granulations,  with  the  advice  to  have  the  wound  fur- 
ther dressed.      Rapid  healing. 

The  confusion  of  appendicitis  with  acute  cholecystitis  is  not 
so  rare  ;  in  both  diseases  can  the  pains  be  very  similar  and  con- 
centrate themselves  in  the  stomach  and  navel.  In  addition  there 
is  constipation  and  vomiting.  Even  the  relations  of  the  tem- 
perature are  not  decisive.  If  the  liver  is  dislocated  (constriction 
liver),  the  inflamed  gall-bladder  adherent  to  the  colon,  then  one 
feels  actually  in  the  caecal  region  a  tumor  which  can  simulate  a 
peritoneal  exudate,  whilst  it  represents  the  gall-bladder  imbedded 
in  succulent  adhesions.  As  rarely  in  general  as  anaesthesia  is 
necessary  to  be  able  to  make  the  diagnosis  of  acute  cholecystitis, 
so  much  the  more  frequently  does  it  happen  that  patients  with- 
out ana:isthesia  by  the  tension  of  their  recti  render  difficult  an 
exact  palpation,  indeed  even  make  it  impossible.  Then  if  one 
anaesthetizes,  one  is  astonished  how  plastically  the  tumor  stands 
out  from  the  other  abdominal  organs,  and  how,  in  a  way,  it 
stands  and  grows  under  the  fingers.  The  course  in  this  case  at 
first  spoke  for  appendicitis  ;  under  anaesthesia,  however,  it  was 
disclosed  that  the  colleague  had  erred.  No  harm  came  to  the 
patient  through  this  ;  on  the  contrary,  she  decided  for  operation, 
and  by  it  was  freed  from  her  stones,  which  already  had  with  cer- 
tainty caused  her  much  pain.  Perhaps  by  vaginal  examination 
one  might  have  excluded  appendicitis. 

In  the  following  case  the  patient,  who  was  ill  with  an  acute 
cholecystitis,  had  formerly  passed  through  several  attacks  of  epi- 
thyphlitis,  so  that  I  felt  it  justifiable  at  the  same  time  to  remove 
the  appendix. 

Mrs.  M.,  46  years,  from  Pabstorf  Entered,  21.7.  97.  Open, 
-3-  7-  97'  Cystectomy.  Resection  of  the  vermiform  process. 
Discharged,  21.  8.  97.      Cured. 


192  GALLSTONE  DLSEASE. 

Patient  is  sent  to  the  clinic  by  Dr.  Klavehn.  She  is  said  never 
to  have  been  ill,  except  for  3  mild  attacks  of  pain  in  the  ileo- 
caecal  region.  The  attending  physician  diagnosticated  appendi- 
citis. Four  days  ago  Mrs.  M.  fell  ill  with  violent  pains  in  the 
region  of  the  gall-bladder,  which  radiated  toward  the  back. 
Violent  vomiting,  no  movement  of  the  bowels,  no  passage  of 
flatus.  Evening  temp.,  38.7°.  Pulse  strong  and  regular.  No 
jaundice. 

Status  Prsesens. — Powerful,  medium-sized  woman.  No  jaun- 
dice. Heart  and  lungs  normal.  In  the  region  of  the  gall-blad- 
der an  extremely  sensitive  tumor  of  smooth  surface  is  to  be  pal- 
pated, which  moves  with  the  respiration  and  passes  into  the  liver  ; 
its  lower  border  reaches  to  2  finger-breadths  above  the  navel. 
Spleen  not  enlarged.  Urine  contains  no  sort  of  abnormal  con- 
stituents. Temperature,  evening,  38.5°.  Pulse  regular,  strong, 
jj  beats  to  the  minute.      Belly  not  distended,  not  sensitive. 

Diagnosis. — Acute  cholecystitis,  cystic  duct  obstruction. 

Operation  on  23.  7.  97.  Chloroform  anaesthesia.  Longitu- 
dinal incision  in  right  rectus  muscle.  On  opening  the  abdomen 
there  presents  the  tensely  filled  and  with  fibrinous  layers  cov- 
ered gall-bladder.  Adhesions  between  omentum  and  gall-blad- 
der ;  these  are  separated.  Puncture  of  the  gall-bladder ;  in  so 
doing  70  ccm.  of  muddy  serous  fluid  are  evacuated.  After  en- 
larging the  puncture  by  incision,  8  hazelnut-sized  stones  are 
removed.  The  walls  of  the  gall-bladder  are  altered  in  so  great 
a  degree  pathologically  that  one  decides  upon  extirpation  of  the 
gall-bladder.  The  gall-bladder  is  freed  from  its  liver  bed, 
ligated  at  the  cystic  duct,  and  now  cut  away.  Since  the  patient 
is  said  to  have  passed  through  several  inflammations  of  the  ap- 
pendix, the  appendix  is  sought  for  ;  it  is  adherent  to  the  pos- 
terior surface  of  the  caecum  and  ascending  colon.  The  adhe- 
sions were  separated,  and  immediately  after  the  ligature  of  its 
mesenteriolum  the  appendix  was  removed  ;  its  stump  was  over- 
cast and  turned  into  the  caecum.  A  long  tampon  was  introduced 
down   to   the   stump  of  the   cystic   duct,  and  afterwards  the  ab- 


CLINICAL  AND  OPERATION  HISTORIES.  1 93 

dominal  wound  in  great  part  closed  with  sutures.  Duration  of 
the  operation,  i  y^   hours. 

Course. — Immediately  after  the  operation  the  fever  fell  to 
normal.  The  subsequent  course  of  the  disease  was  free  from 
every  sort  of  disturbance.  Well  granulating  wound  cavity.  On 
the  14th  day  after  the  operation  the  patient  left  her  bed. 
The  wound  constantly  diminishes.  Her  strength  so  increases 
that  Mrs.  M.  already  on  the  21.8.  could  be  discharged  as  cured 
except  for  an  about  mark -sized  granulating  surface. 

A  combination  of  cholecystitis  with  pancreatitis  chronica  inter- 
stitialis  is  illustrated  by  the  following  case  : 

A.  K.,  27  years,  carpenter's  wife,  from  Halberstadt.  Entered, 
16.  2.  98.  Open,  17.  2.  98.  Resection  of  gall-bladder.  Dis- 
charged, 22.  3.  98.  (?)  Re-entry,  20.  5.  98.  Open,  24.  5.  98. 
Cystico-gastrostomy,  gastro-enterostomy.    Discharged,  16.  7.  98. 

Parents  of  patient  dead  (father  of  consumption,  mother  of 
ulcer  of  the  stomach)  ;  two  brothers  still  living  ;  patient  married 
at  19  years  old,  mother  of  four  children,  of  which  three  live 
and  are  healthy.  In  September,  1897,  the  patient  suddenly  was 
attacked  with  shortness  of  breath,  together  with  pains  in  the 
stomach  and  between  the  shoulder-blades.  The  doctor  diag- 
nosticated gallstone  colic,  and  ordered  hot  applications  ;  laxa- 
tives were  vomited.  Finally  stool  followed  liquid  medicine,  and 
through  this  her  condition  improved.  Jaundice  is  said  never  to 
have  been  present.  Patient  was  afterwards  quite  well  and  toler- 
ated all  foods.  In  the  middle  of  January,  1898,  she  suddenly 
had  pains  in  the  stomach,  without  vomiting,  but  with  eructa- 
tions. The  pains  varied  some  days  in  their  strength,  until  on 
the  third  day  their  violence  became  very  great,  and  sacral  pains 
were  added  to  them.  These  attacks  now  occurred  almost  every- 
day. If  vomiting  occurred  the  patient  felt  better.  On  entrance, 
38.7.,  pulse  96°.      Sent  by  Dr.  Bottichen 

Status  Prsesens. — Medium-sized,  rather  thin  woman,  slightly 
icteric.  Organs  normal,  urine  free  from  albumin  and  sugar  ;  it 
contains  bile  coloring  matters.      Without  anaesthesia  one  finds  in 


194  GALLSTONE  DISEASE. 

the  right  side  of  the  upper  portion  of  the  abdomen  increased 
resistance,  to  the  right  of  the  navel  a  pronounced  sensitiveness 
to  pressure  and  an  indistinctly  palpable  tumor. 

Diagnosis. — Cholecystitis  ;  at  present  acute  cholecystitis. 

Operation. — Chloroform  anaesthesia.  Duration,  65  minutes. 
Rather  short  longitudinal  incision  in  right  rectus  abdominal 
muscle  from  curvature  of  the  ribs  downwards.  One  comes 
upon  liver  reaching  to  the  level  of  the  navel ;  this  is  the 
tumor  previously  felt.  The  gall-bladder  is  not  visible,  it  is  inti- 
mately adherent  to  the  inflamed  omentum.  It  is  possible  only 
with  difficulty  to  free  the  gall-bladder,  which  further  is  adherent 
to  the  stomach  and  to  the  greatest  part  of  the  posterior  surface 
of  the  duodenum.  In  so  doing  its  thickened  and  soft  wall 
tears.  There  appear  in  view  a  number  of  small  to  pea-sized 
roundish  yellow  stones  with  thick  pus.  Gauze  compresses  had 
previously  been  introduced  for  protection  of  the  belly.  The 
stones  were  removed  with  forceps.  One  intends  to  extirpate 
the  gall-bladder,  but  finds  the  adhesions  on  the  posterior  surface 
separable  only  with  great  difficulty ;  besides  it  is  also  evident 
that  perforations  have  occurred,  and  that  stones  still  lie  behind 
the  bladder  in  the  adhesions  ;  the  removal  of  these  is  very  diffi- 
cult ;  on  this  account  one  removes  so  much  of  the  gall-bladder 
wall  that  only  in  fact  the  hardened  posterior  wall  and  the  part 
of  the  bladder  lying  next  to  the  cystic  duct  remain.  With  this 
a  severe  bleeding  takes  place  from  the  cystic  artery,  which  is 
controlled  by  ligature.  Now  there  yet  stick  two  stones  in  the 
cystic  duct,  w^iich  are  removed  with  great  difficulty.  Then  the 
bladder  is  sewn  upon  itself,  some  omental  bands  are  ligated,  a 
strip  of  gauze  introduced  down  to  the  sutures,  and  the  abdomi- 
nal wound  closed  by  through  and  through  interrupted  and 
some  skin  sutures.  In  the  gall-bladder  twenty-nine  stones. 
Pulse  very  small,  100.  Mrs.  K.  vomits  on  the  succeeding 
days  until  the  21.  2.  very  frequently  bilious  fluid;  on  outwashing 
of  the  stomach  the  vomiting  stops.  Belly  always  soft.  No 
fever.    On  24.  2.  again  vomiting  occurs,  which  requires  outwash- 


CLINICAL  AND  OPERATION  HISTORIES.  1 95 

ing  of  the  stomach.  Subsequently  the  patient  complains  very 
often  of  pain  in  the  stomach,  particularly  after  more  solid  food. 
It  is  necessary  also  again  on  the  3.  3.  98  to  once  wash  out  the 
stomach,  but  afterwards  the  patient  slowly  gains  strength  and 
tolerates  all  foods,  although  only  in  moderate  quantities. 

On  the  first  change  of  dressings,  on  the  26.  2.,  some  bile  is 
found  in  the  dressing.  The  escape  of  bile  subsequently  be- 
comes greater,  so  that  dressings  must  be  changed  already  on 
the  28.  2.,  then  on  5.  3.,  11.  3.,  15.  3.,  22.  3.  Already  on  the 
15.  3.  is  the  escape  of  bile  very  small,  therefore  Mrs.  K.  is' dis- 
charged on  the  22.  3.  with  a  small  granulation  and  a  somewhat 
secreting  bile  fistula.  Subsequently  Mrs.  K.  comes  to  the  cHnic 
for  dressing  ;  the  fistula  constantly  excretes  bile,  sometimes,  in- 
deed, very  profusely.  If  it  is  plugged  with  gauze  or  becomes 
very  narrow,  then  severe  pains  in  the  stomach  occur  with  vomit- 
ing of  bile  colored  contents  of  the  stomach  ;  immediately  upon 
the  expulsion  of  a  large  quantity  of  bile  from  the  fistula,  well- 
being  again  returns.  The  skin  of  the  abdomen  is  irritated  over 
a  considerable  surface  by  the  bile,  on  this  account ;  and  finally,  to 
regain  health,  Mrs.  K.  resolves  upon  a  secondary  operation. 
Again  received,  20.  5.  98.  The  fistulous  tract  is  dilated  with  a 
laminaria  tent  ;  this  is  removed  on  the  following  day  ;  bile  soon 
escapes.  Tamponade  of  the  fistula.  On  the  24.  5.  98  operation. 
Median  incision  from  the  ensiform  process  almost  to  navel,  then 
inclining  toward  the  left,  toward  the  left  ant.  superior  spinous  pro- 
cess. The  large  stomach  is  toward  the  right  adherent,  especially 
in  the.  region  of  the  cicatrix  to  the  parietal  peritoneum.  One 
feels  above  the  greater  curvature  of  the  stomach  the  Jiardcncd 
and  enlarged  pancreas,  which  compresses  strongly  the  chole- 
dochus,  in  which  no  stone  is  detectable.  Separation  of  the 
stomach  from  the  peritoneum  ;  in  so  doing  the  stomach  tears, 
partial  suture  of  the  opening.  The  gall-bladder  stump  is  put  in 
anastomosis  with  the  stomach  at  the  point  of  the  tear  in  the 
stomach.  Cystico-gastrostomy.  Afterward  gastro-enterostomy 
with  suture,  according  to   Hacker,  on  account  of  dilatation    of 


196  GALLSTONE  DLSEASE. 

the  stomach.  Dilatation  of  the  fistulous  tract.  Gauze  tampon 
in  the  foramen  of  Winslow.  Closure  of  the  abdominal  wound, 
after  excision  of  the  navel,  with  through  and  through  interrupted 
sutures  and  a  few  skin  sutures.  On  the  evening  of  the  operation 
the  temp,  is  37.2°  ;  on  next  day  early,  39°  ;  evening,  39.1°  ;  then 
the  temperature  falls,  and  from  28.  5.  it  remains  in  normal  limits. 
On  the  27.  5.  the  bandage  shows  itself  soaked  with  bile,  and  is, 
therefore,  changed.  One  discovers  that  the  anastomosis  on  the 
anterior  wall,  to  which  the  gauze  reaches,  has  not  held  ;  a  biliary- 
stomach  fistula  has  formed.  Afterwards  Mrs.  K,  must  be  dressed 
often,  2  or  3  times  a  day.  Several  attempts  were  made  to  re- 
store the  anastomosis  by  sutures,  thus  on  30.  5.,  i.  6.,  4.  6.,  but 
it  is  not  successful  since  the  sutures  cut  out  and  consequently 
the  patient  must  be  frequently  dressed  ;  she  is  discharged  on 
the  16.  7.  without  a  cure  resulting,  and  comes  daily  to  the  clinic 
for  dressing.  Marked  improvement  in  the  general  condition  ; 
the  woman  now  appears  in  glowing  health  ;  she  indeed  performs 
field  labor.  For  a  half  year  the  patient  has  been  doing  well. 
She  dresses  herself,  and  comes  only  every  four  weeks  to  the 
clinic.      Escape  of  bile  extremely  small. 


5- 
Acute  Cholecystitis  in  a  Contracted  Gail-Bladder. 

Freqncnt  iuJI a?  in  nations  in  the  gall-bladder  lead  gradually  to  a 
shrinking  of  the  organ,  so  that  even  tlien,  when  a  purulent  chole 
cystitis  arises,  a  tumor  of  the  gall-bladder  is  not  to  be  felt,  since  the 
organ  Jias  lost  its  distensibility. 

Of  this  I  give  three  examples. 

(a)  Mrs.  P.,  53  years,  from  Husum.  Entered,  26.  3.  97. 
Operation,  29.  3.  97  and  10.  4.  97.  Cystostomy  in  two  stages. 
Discharged,  23.  5.  97.      Cured. 

Patient,  the   mother  of  a  healthy  child,  is  said  to   have  been 


CLINICAL  AND  OPERATION  HISTORIES.  1 97 

perfectly  healthy  up  till  1866.  About  this  time  she  fell  ill  with 
severe  cramps  in  the  stomach,  attended  by  vomiting  and  consti- 
pation. These  attacks  were  repeated  several  times  in  the  same 
year  ;  then  the  patient  remained  well  until  1889,  when  the  same 
trouble  again  appeared.  From  that  time  on  followed  mild  at- 
tacks until  the  year  1889,  when  especially  violent  attacks  with 
the  passage  of  an  about  pea-sized  gallstone  occurred.  Despite 
the  passage  of  the  stone  other  attacks  compelled  the  patient  to 
go  to  Carlsbad.  The  four-weeks  cure  brought  no  relief  Con- 
tinual feeling  of  pain  without  real  colic  up  till  the  year  1895, 
when  again  with  the  most  violent  pains  two  stones  about  hazel- 
nut-size passed.  With  this  attack  for  the  first  time  jaundice. 
Since  an  improvement  in  spite  of  the  most  different  remedies 
would  not  result,  the  patient  decided  in  March,  1897,  for  opera- 
tion, after  she  had  this  year  passed  through  an  especially  violent 
colic,  attended  by  jaundice,  but  without  the  passage  of  stones. 

Status  Prsesens. — Very  corpulent  woman,  of  healthy  ap- 
pearance. No  jaundice.  Heart  and  lungs  normal.  Liver  and 
spleen  not  enlarged.  In  the  region  of  the  gall-bladder  there 
exists  marked  sensitiveness  to  pressure.  No  palpable  tumor. 
Urine  is  free  from  albumin,  biliary  coloring  matters  and  sugar. 
Brown-colored  stools.  No  fever,  pulse  regular,  strong,  83  beats 
in  the  minute. 

Diagnosis. — Adhesions,  stones  in  the  gall-bladder. 

Operation  on  the  29.  3.  97.  Choloroform  anaesthesia.  Lon- 
gitudinal incision  in  the  right  rectus  abdominal  muscle.  On 
opening  the  abdomen  the  small  liver  is  seen  lying  high  up  under 
the  ribs.  Gall-bladder  is  not  visible.  For  the  first  after  the 
separation  of  numerous  firm  adhesions,  which  lead  from  the 
omentum  and  stomach  to  the  fundus  of  the  gall-bladder,  it  be- 
comes possible  to  feel  the  latter.  On  separation  of  the  adhe- 
sions in  the  belly  the  pulse  and  breathing  often  stop.  Since  the 
pulse  remains  persistently  very  small,  one  decides  upon  an  oper- 
ation in  two  stages.  After  that  the  gall-bladder  with  great  diffi- 
culty is  separated  from  adhesions  and  is   made  visible,  it  is  at- 


198  GALLSTONE  DISEASE. 

tached  with  2  sutures  to  the  parietal  peritoneum,  and  immedi- 
ately after  its  entire  surroundings  firmly  tamponed.  In  the  gall- 
bladder two  stones  were  felt ;  the  cystic  and  common  ducts  free 
from  stones.  Partial  closure  of  the  abdominal  wound.  Dura- 
tion of  the  operation,  i  ^  hours. 

Patient  has  borne  the  operation  well ;  no  fever  appeared  ;  on 
the  second  day  after  the  operation  spontaneous  expulsion  of 
flatus.  After  the  completion  of  12  days,  on  the  loth  of  April, 
1897,  I  proceeded  to  operation,  since  it  can  by  this  time  be 
assumed  that  the  surroundings  of  the  gall-bladder  have  shut 
themselves  well  off  from  the  free  cavity  of  the  abdomen.  At 
first,  without  anaesthesia,  an  attempt  at  incision  was  made,  but 
since  it,  on  account  of  the  restlessness  of  the  patient  and  the 
extraordinary  depth  at  which  the  gall-bladder  lay  proved  itself 
impracticable,  chloroform  anaesthesia  was  induced.  The  right 
ribs  were  drawn  by  sharp  retractors  strongly  upwards  ;  in  the 
depths  the  gall-bladder  was  visible.  Puncture  of  it ;  thus  some 
50  ccm.  of  muddy  bile  was  removed.  The  gall-bladder  was 
now  opened  by  incision  ;  the  probe  introduced  comes  upon  a 
stone  ;  it  is  possible  to  grasp  this  with  a  long-curved  dressing 
forceps,  but  not  to  extract  it.  In  the  branches  of  the  forceps 
are  fine  stone  fragments.  In  the  opened  gall-bladder  a  large 
tube  was  introduced  ;  then  dressing,  since  on  account  of  the  small 
pulse  a  prolonged  anaesthesia  seemed  dangerous. 

With  the  succeeding  dressings  were  stone  fragments,  removed 
partly  by  irrigation  and  partly  with  forceps.  After  long  endeav- 
ors finally  all  remains  are  removed,  in  the  gall-bladder  no  stone 
is  to  be  felt.  Bile  escapes,  a  proof  that  the  cystic  duct  is  patent. 
The  healing  now  advances  without  hindrance,  so  that  the  patient 
can  be  discharged  on  the  23.  5. 

In  this  case  one  was  of  necessity  obliged  to  decide  for  an 
operation  in  two  stages,  since  the  anaesthetic  was  borne  extra- 
ordinarily ill.  But  one  sees  from  the  very  protracted  course 
how  difficult  it  is  to  remove  all  stones  by  cystostomy  in  two 
stages.     At  all  events,  in  the  cases  in  which  it  is  at  all  suitable, 


CLINICAL  AND  OPERATION  HISTORIES.  .     1 99 

the  immediate  cystostomy  is  to  be  preferred  to  that  in  two  stages. 
Only  in  case  of  weakness  in  very  high  degree  of  the  patient  is 
the  latter  indicated. 

(b)  Dr.  S.,  39  years,  from  Menado,  Island  of  Celebes.  En- 
tered, 22.  5.  98.  Oper.,  24.  5.  98.  Cystostomy.  Secondary 
cystocotomy.      Discharged,  10.  7.  98. 

Amnesis. — Father  dead  (inflammation  of  lung),  mother  liv- 
ing in  good  health  ;  of  altogether  9  brothers  and  sisters,  4  are 
still  living,  the  3  remaining  are  healthy  except  a  sister,  who  suf- 
fers from  cramps  of  the  stomach — ascribed  to  nervous  dyspep- 
sia. As  a  child  the  patient  suffered  from  typhoid,  and  later  (16 
years  old)  from  a  catarrh  of  the  lungs  with  bloody  expectoration. 
In  1884  the  patient  went  to  India  ;  he  was  obliged  to  suffer  much 
from  malaria  and  other  febrile  diseases.  He  did  not  get  dysen- 
entery.  Cramps  of  the  stomach  appeared  about  4  years  ago  ; 
they  consisted  of  pains  in  the  pit  of  the  stomach,  which  radiated 
to  the  back.  The  duration  of  the  attacks  of  pain  was  at  most 
y^  hour,  their  frequency  was  rare  ;  in  the  course  of  the  next 
year  they  increased  in  frequency  and  intensity.  Already  in  1895 
a  physician  diagnosticated  gallstones.  He  employed  Carlsbad 
salts  with  transitory  success.  Malaria  still  existed.  The  general 
condition  became  constantly  worse  in  the  meantime,  so  that  the 
patient  in  April,  1897,  was  obliged  to  betake  himself  to  Europe. 
During  the  voyage  the  patient  suffered  from  fever,  probably  mala- 
rial. Consultations  took  place  in  Europe  with  numerous  physicians, 
who  pronounced  themselves  for  gallstones.  Colics  afterwards  as 
before.  Malaria  was  brought  to  a  cure  by  a  stay  in  the  moun- 
tains. The  gall-bladder  was  not  palpable.  The  last  colic  was 
at  the  end  of  April,  1898  ;  its  severity  was  slight,  radiating  pains 
in  the  back  and  shoulders  ;  it  did  not  come  to  real  cramps,  but 
there  existed  a  vague  but  very  pronounced  sensitiveness  of  the 
whole  hypochondrium.  Since  then  dull  pains  in  the  right  upper 
abdominal  region  ;  sometimes,  also,  somewhat  to  the  right  of  the 
navel,  piercing  pains.  Patient  inclined  to  diarrhoea.  With  the 
cramp  attacks  vomiting  occurred.  Dr.  Pel  of  Amsterdam  and 
Dr.  Ritter  of  Carlsbad  advise  operation. 


200  GALLSTONE  DISEASE. 

Status  Praesens. — Large,  powerfully-built  man,  in  heart  and 
lungs  no  pathological  condition  demonstrable.  Region  of  the 
liver  sensitive  to  pressure,  painful  point  on  pressure  outside  of 
the  right  rectus  somewhat  above  the  navel  ;  no  tumor.  Urine 
free  from  albumin,  sugar  and  biliary  coloring  matters. 

Diagnosis. — Shrunken  gall-bladder  with  stones,  after  frequent 
attacks  of  cholecystitis. 

Operation. — Chloroform  anaesthesia.  Duration  almost  2 
hours.  Bad  anaesthesia.  Longitudinal  incision  in  the  right 
rectus  abdominal  muscle  from  the  curvature  of  the  ribs  down- 
wards extending  below  the  navel,  later  lengthened  upwards  to- 
wards the  median  line.  One  finds  after  separation  of  omental 
adhesions  a  shrunken  gall-bladder  with  its  fundus  concealed 
under  the  liv^er  border.  Other  adhesions  which  bind  the  gall- 
bladder to  the  omentum  and  stomach  must  be  separated,  which 
on  account  of  the  great  depth  is  very  difficult.  The  separation 
of  the  adhesions,  which  go  from  the  stomach  to  the  under  side 
of  the  liver  and  the  cystic  duct,  delays  especially  long.  The 
gall-bladder  to  deep  into  the  cystic  duct,  is  crammed  with  stones  ; 
it  is  not  possible  to  press  up  the  stones.  On  this  account  the 
gall-bladder  is  separated  from  the  liver,  and  it  is  again  attempted 
to  remove  the  stones.  This  does  not  succeed,  at  the  same  time 
the  anaesthesia  is  very  bad  and  the  breathing  often  ceases.  One 
concludes  to  sew  the  unopened  gall-bladder  into  the  wound  ;  in 
so  doing  the  wall  tears,  one  is  obliged  to  open  the  gall-bladder, 
the  escaping  fluid  is  wiped  away,  and  3  cherry-sized  stones  (2 
mulberry  and  i  black  stone)  are  removed.  Other  stones  do  not 
admit,  since  they  stick  too  firmly,  of  removal.  On  this  account 
is  the  space  between  the  under  surface  of  the  liver  and  gall-blad- 
der tamponed,  the  gall-bladder  only  partly  sewed  into  the  wound. 
Tampon  on  its  under  surface.  Closure  of  the  lower  part  of  the 
abdominal  wound  by  through  and  through  interrupted  sutures, 
tampons  all  about  the  opening  of  the  gall-bladder,  in  which  a 
tube  is  introduced.  Suture  of  portion  of  the  wound  at  the  cur- 
vature of  the  ribs  with  through  and  through  interrupted  sutures 


CLINICAL  AND  OPERATION  HISTORIES.  201 

and  a  few  skin  sutures.  On  the  evening  of  the  operation  the 
temperature  was  38.2°,  and  kept  about  38°  until  5.  6.  ;  its  high- 
est point  was  reached  i.  6.  with  38.8°.  Patient  vomited  fre- 
quently the  first  few  days  ;  on  the  26.  5.  escape  of  bile  was 
noticed.  Afterwards  constant  escape  of  bile.  On  the  i.  6.  the 
first  change  of  dressings  occurred,  the  sutured  wound  was  healed; 
for  an  hour  without  anccsthesia  an  attempt  was  made  to  remove 
the  concretions,  but  it  failed.  Afterwards  the  flow  of  bile  stopped. 
On  4.  6.  a  fresh  change  of  dressings  was  undertaken,  it  was  pos- 
sible with  great  care  to  remove  a  stone,  after  space  was  first 
made  by  an  incision  of  about  2  cm.  length  on  the  anterior  wall 
of  the  gall-bladder,  then  by  an  incision  situated  at  the  side  on 
the  left  extending  to  the  cystic  duct.  The  stone,  which  was 
about  the  size  of  a  cherry,  could  be  removed  first  only  when  in 
part  it  was  broken  in  fragments.  On  6.  6.  bile  again  flowed,  on 
7.  6.  the  dressing  was  renewed,  the  bladder  irrigated  and  search 
made  for  any  fragments  of  stone  ;  none  were  detected.  After- 
wards dressings  w^ere  changed  9.,  12.,  16.,  20.,  24,,  30.,  6.  ;  5., 
9.  7.  Wound  healed  very  slowly.  After  the  7.  7.  no  more 
escape  of  bile.  On  the  10.  7.  the  patient  was  discharged  with 
healed  wound,  and  no  hernia,  in  the  best  of  health. 

From  the  first  news  the  patient  again  had  pains  in  the  stom- 
ach. I  do  not  believe  that  a  stone  still  is  lodged  in  the  cystic 
duct,  for  with  a  probe  one  could  feel  nothing.  But  the  possi- 
bility that  a  stone  still  remains  is  not  entirely  to  be  disregarded. 
If  it  is  the  case,  then  at  all  events  the  removal  would  be  very 
difficult.  The  patient  is  said  to  eat  very  eagerly  and  abundantly, 
and  so  may  the  pains  in  the  stomach  be  explained  by  the  drag- 
ging upon  the  pylorus  of  the  inevitable  adhesions.  In  such  a 
case  a  gastro-enterostomy  should  be  undertaken,  if  dietetic 
means  do  not  lead  to  success. 

That  it  is  most  probable  that  a  stone  still  remains,  is  proven 
by  the  following  letter  from  the  patient,  which  was  sent  to  me 
by  a  relative. 

Patient  writes  on  13.  10. 
17 


202  GALLSTONE  DISEASE. 

''  I  was  obliged  constantly  on  the  whole  voyage  to  suffer  from 
cramps,  from  which  I  could  only  get  relief  by  morphine  injec- 
tions. In  Singapore  I  was  attacked  with  fever,  and  later  by 
headache,  so  that  I  was  glad  to  arrive  in  Batavia  on  the  lo.  lO., 
where  I  still  could  rest.  On  the  12.  10.  I  had  cramps,  vomit- 
ine,  and  there  formed  in  the  scar  a  sort  of  bladder,  so  that  I 
immediately  thought  that  the  thing  would  burst  open,  for  the 
wound  had  for  so  long  occasioned  me  from  within  out  such 
piercing  pain  on  coughing.  This  morning  (13.  10.)  on  awak- 
ing I  found  myself  lying  in  a  bath  of  bile  ;  as  a  precautionary 
measure  I  had  already  yesterday  evening  disinfected  the  bladder 
formation  and  its  neighborhood  w^ith  permanganate  of  potash 
and  applied  a  dressing  of  wadding  ;  this  was  now  completely 
soaked  with  bile.  The  doctor  says  this  perforation  was  the  sav- 
ing of  me  ;  that  it  is  a  wonder  that  the  bile  stored  up  in  the 
belly,  which  now  has  made  a  way  out  for  itself,  had  not  set  up  a 
peritonitis.  I  believe  that  the  old  internal  wound  by  a  walk  in 
the  mountains  before  my  departure  had  been  torn  apart,  and 
that  from  then  till  now  the  bile  has  in  part  entered  the  belly  and 
has  distended  this,  hence  the  distended  region  of  the  stomach 
and  the  cramps  which  have  since  then  persisted.  Last  night  I 
was  completely  *  emptied,'  therefore  the  escape  of  bile  ceased, 
but  it  has  now  returned.  An  opening  about  the  size  of  a  lead- 
pencil  goes  into  the  abdomen,  from  which  bile  mixed  with  water 
pours  out.  I  have  no  pain,  but  must  keep  very  quiet,  in  accord- 
ance with  the  orders  of  my  doctor.  22.  10.  my  condition  does 
not  accord  with  my  wishes.  I  begin  to  doubt  whether  I  ever 
will  again  be  sound.  The  doctor  says  there  is  no  present  danger, 
although  at  times  I  suffer  from  high  fever.  31.  10.  my  health  is 
very  poor.  After  that  the  biliary  fistula  had  closed,  it  has  now 
again  broken  out  with  violent  pains  and  high  fever,  and  I  feel 
myself  a  sufferer ;  no  wonder,  for  the  biliary  fistulae  usually  end 
fatally,  unless  they  do  close  of  themselves.  It  remains  only 
to  wait  and  see  how  things  go  in  the  future." 

The  case  shows  the  difficulties  which  one  stumbles  on  in  con- 
tracted gall-bladders.     Is  there  a  stone  still  in  the  gall-bladder  ? 


CLINICAL  AND  OPERATION  HISTORIES.  203 

It  is  to  me  at  the  present  very  probable.  Of  peritonitis,  the 
danger  feared  by  the  attending  physician,  there  can  be  no 
thought.  The  bile  can  occasion  here  absolutely  no  injury,  yet 
it  will  be  necessary  to  dilate  the  fistula  with  a  laminaria  tent,  so 
as  to  search  for  and  remove  any  stones.  I  have  advised  the 
patient  again  to  journey  to  Germany  and  submit  himself  to 
further  treatment.     A  stone  in  the  choledochus  is  improbable. 

(c)  L.  H.,  51  years,  wife  of  a  farm  overseer,  from  Wolfen- 
biittel.  Entered,  28.  4.  98.  Operation,  29.  4.  98.  Cystectomy 
and  closure  of  stomach  fistula.     Discharged,  28.  5.  98.     Cured. 

Amnesis. — Parents  dead,  of  nine  brothers  and  sisters  six  are 
still  living  who  are  healthy.  Mrs.  H.,  as  a  child,  was  always  ill 
(gastric  fever) ;  married  at  27  years  ;  mother  of  a  prematurely 
born  child  (7  months),  which  died  in  its  14th  year;  besides  she 
has  had  5  miscarriages.  Ten  years  ago  she  suddenly  was  taken 
with  cramps  in  the  stomach,  which  occurred  in  frequent  attacks 
of  short  duration.  Vomiting  occurred  sometimes  with  these  ; 
likewise  jaundice.  Mrs.  H.  then  had  violent  pains  on  the  right 
under  the  curvature  of  the  ribs,  so  that  she  went  entirely  bent 
over.  After  three  months  her  condition  improved.  Now  for 
ten  years  she  felt  thoroughly  well,  except  that  occasionally  there 
was  pain  in  the  region  of  the  stomach,  and  all  foods  were  not 
well  borne.  At  the  end  of  February,  1898,  the  patient  fell  ill 
again,  as  she  states,  with  grippe ;  after  8  days  jaundice  appeared 
and  violent  pains  occurred  in  the  right  side  of  the  upper  part  of 
the  abdomen.  Vomiting  was  wanting;  the  bowels  were  consti- 
pated. The  jaundice  disappeared  in  a  week,  the  pains  remained, 
the  general  condition  improved  and  got  worse,  the  patient  could 
not  lie  outstretched.    Dr.  Breymann  sent  the  patient  to  my  clinic. 

Status  Prsesens. — Scarcely  medium-sized,  pretty  spare,  sick- 
looking  woman  with  bent  carriage,  which  comes  from  the  co- 
lossal painfulness  which  involves  the  whole  gall-bladder  region 
to  almost  the  level  of  the  navel.  One  there  feels  a  resistance, 
which  is  referred  to  an  inflamed  gall-bladder.  In  the  remaining 
organs  nothing  of  note.  Urine  normal.  Temperature,  38.7°  C. 
Pulse,  no. 


204  GALLSTONE  DISEASE. 

Diagnosis. — Cholecystitis  acuta  purulenta  with  cystohthiasis. 
Operation. — Chloroform  anaesthesia.  Longitudinal  incision 
in  the  right  rectus  abdominal  muscle  from  the  ribs,  extending 
downward  to  somewhat  under  the  navel ;  after  separation  of  the 
skin  and  muscle  one  comes  to  the  peritoneum,  which  shows  ad- 
hesions with  the  underlying  structures.  In  the  region  in  which 
one  assumes  the  gall-bladder  to  be  a  puncture  is  made  with  a 
Pravaz  syringe,  and  soon  also  some  pus  is  removed.  By  incision 
one  opens  into  a  cavity  which  is  recognized  as  the  gall-bladder 
and  contains  many  stones  and  pus.  Adhesions  of  the  gall- 
bladder with  the  stomach.  On  separating  them  a  tear  occurs  in 
the  stomach,  from  which  the  mucous  membrane  protrudes  ;  this 
is  closed  with  six  silk  sutures.  Tamponade  down  to  the  stump 
of  the  cystic  duct,  through  and  through  interrupted  sutures  of 
the  abdominal  wound,  a  few  skin  sutures  ;  the  upper  angle  of 
the  wound  remains  open. 

Course. — The  dressings  are  soaked  through  on  4.  5.  98  and 
are  therefore  changed;  the  sutures  in  the  stomach  have  not  all 
completely  held  ;  some  of  the  stomach  contents  escape.  Subse- 
quent frequent  change  of  dressings,  since  the  escaping  fluid 
erodes  the  surrounding  skin.  On  the  change  of  dressings  on 
the  20.  5.  98  the  fistula  is  seen  to  be  closed,  broad  granulations 
at  the  plane  of  the  skin,  remaining  wound  healed,  skin  slightly 
eroded.  The  healing  makes  rapid  advances,  so  that  Mrs.  H.  is 
discharged  on  28.  5.  98  with  a  small  granulation  at  the  upper 
angle  of  the  wound.      Cure.      Feeling  excellent. 


6. 
Hydrops  Chronicus    Cystidis  Felleae. 

We  learn  to  recognize  a  typical  case  of  chronic  dropsy  of  the 
gall-bladder  by  the  following  case  : 

Mrs.  B.,  ^j  years,  from  Magdeburg.  Entered,  27.  5.  97. 
Oper.,    29.  5.  97.      Cystostomy  and  cysticotomy.      Discharged, 


CLINICAL  AND  OPERATION  HISTORIES.  205 

18.  6.  97.  Cured,  10.  7.  97.  Patient  the  mother  of  four  healthy 
children,  is  said  to  have  been  always  healthy  until  four  years 
ago.  About  this  time  she  fell  ill  with  cramps  in  the  stomach, 
vomiting,  constipation,  violent  pains  in  the  pit  of  the  stomach, 
which  radiated  towards  the  right  axilla  and  the  back.  In  all,  the 
patient  had  to  undergo  six  of  these  attacks.  Jaundiced  she  has 
never  been.  Since  the  beginning  of  February  she  has  noticed 
a  tumor  in  the  region  of  the  gall-bladder  which  was  very  sensi- 
tive to  pressure.  Since  the  tumor  did  not  again  disappear,  Mrs. 
B.  decided  upon  operation. 

Status  Praesens. — Small,  spare  woman.  No  jaundice.  Heart 
and  lungs  normal.  In  the  region  of  the  gall-bladder  marked 
sensitiveness  to  pressure.  There  there  is  to  be  palpated  a  tumor 
of  egg-shape,  whose  upper  limits  pass  into  the  liver  and  whose 
lower  limits  are  two  finger-breadths  below  the  navel.  The  skin 
over  the  tumor  is  movable.  In  respiration  evident  movement  of 
the  tumor.  Spleen  not  enlarged.  No  fever.  Pulse  regular, 
strong,  80  beats  to  the  minute.  Urine  contains  no  abnormal 
constituents.      Brown  stools. 

Diagnosis. — Chronic  cholecystitis ;  lithogenous  obstruction 
of  the  cystic  duct. 

Operation  on  the  29.  5.  97.  Chloroform  aucxsthesia.  Longi- 
tudinal incision  in  the  right  rectus  abdominal  muscle  from  cur- 
vature of  the  ribs  to  the  navel.  Upon  opening  the  belly  there 
presented  the  tensely  filled  gall-bladder,  and  stretched  upon  it 
the  sharp  liver  border.  Broad,  flat  adhesions  between  gall- 
bladder, omentum  and  colon.  After  the  separation  of  the  adhe- 
sions the  gall-bladder  is  punctured  ;  with  this  there  is  discharged 
about  100  ccm.  of  sero-purulent  fluid.  The  puncture  is  en- 
larged by  incision,  and  afterwards  the  gall-bladder  plugged  with 
gauze.  On  palpation  of  the  large  bile  ducts  one  feels  in  the 
cystic  duct  a  firmly-wedged  stone,  which  does  not  permit  itself 
to  be  pushed  into  the  gall-bladder,  therefore  an  incision  is  made 
upon  it  and  it  is  extracted.  Choledochus  and  hepaticus  are  free 
from  stones.      Closure  of  the  wound  in  the  cysticus  by  5  sutures, 


206  GALLSTONE  DISEASE. 

thereupon  attachment  of  the  gall-bladder  to  the  parietal  perito- 
neum. Suture  of  the  peritoneum  and  the  greatest  part  of 
wound  in  the  abdominal  walls.  Introduction  of  a  large  tube 
into  the  gall-bladder.  Dressing.  Duration  of  the  operation 
one  hour.  The  course  was  normal.  Patient  had  no  fever.  On 
the  4th  day  after  operation  bile  escaped.  In  the  beginning  dress- 
ings necessarily  changed  twice  a  day.  The  escape  of  bile 
diminished  soon,  so  that  the  patient  could  be  discharged  with  a 
scantily  excreting  fistula  on  the  18.  6.  Definitively  had  the 
fistula  closed  on  the  10.7.  Condition  of  the  patient  excellent 
at  a  recent  interview.  Afterwards  the  patient  fell  ill  with  nephro- 
lithiasis, with  severe  bleeding  and  the  passage  of  stones.  Further 
information  is  wanting.  Just  as  typical  are  the  two  following 
cases : 

(a)  Mr.  D.,  44  years,  postmaster,  from  Braunslage.  Entered, 
19.  I.  97.  Oper.,  21.  I.  97.  Cystostomy,  cysticotomy.  Incision 
of  a  diverticulum.  Discharged,  2.  3.  97.  Cured.  Patient  is 
said  to  have  suffered  since  1875  with  distress  in  the  stomach  ; 
this  occurred  especially  after  eating  fatty  foods.  Vomiting  and 
real  cramps  of  the  stomach  appeared  first  in  the  year  1883.  At 
that  time  the  stools  were  irregular,  and  besides  there  existed 
pain  on  pressure  in  the  region  of  the  gall-bladder.  Since  medi- 
cine brought  him  no  relief  he  visited  various  medical  establish- 
ments. First  was  he  treated  in  the  year  1884  at  a  cold-water 
cure  institution  at  Lauterberg  and  Thale.  No  success  ;  there- 
fore he  went  in  December,  1885,  to  Carlsbad.  A  four  weeks' 
cure  which  he  there  passed  through  brought  him  improve- 
ment, but  after  only  6  weeks  renewed  violent  attack.  In  the 
following  5  years  there  followed  still  several  typical  colics  at 
different  intervals.  He  is  said  never  to  have  been  free  from 
the  feeling  of  distension.  1890  he  visited  a  natural  cure  institu- 
tion in  Berlin,  without  success;  1892  he  tried  at  Chemnitz  a 
Kneipp  cure,  with  the  same  result  ;  1896  he  was  treated  4  weeks 
by  a  "physiological  chemist"  with  sulphur,  lime  and  iron  prep- 
arations.    After  this  cure  he  is  said  to  have  been  3  months  free 


CLINICAL  AND  OPERATION  HISTORIES.  20/ 

from  pain.  At  the  end  of  December,  1896,  again  a  violent 
attack ;  the  patient  therefore  decided  upon  an  operation. 
During  the  attacks  mild  jaundice  is  said  to  have  always  existed. 
The  stools  were  then  clayey  and  the  urine  beer-brown. 

Status  Prsesens. — Large,  powerfully-built  man.  No  jaun- 
dice. Heart  and  lungs  normal.  In  the  region  of  the  gall- 
bladder a  tumor  the  size  of  a  hen's  egg  to  be  palpated,  which 
moves  with  the  respiration.  The  tumor  has  a  smooth  superior 
surface  and  is  of  tense-elastic  consistence  ;  its  lower  borders  two 
finger-breadths  above  the  navel,  the  upper  limits  pass  into  the 
liver  dullness.  Over  the  tumor  dull  tympanitic  resonance. 
Spleen  and  liver  are  not  enlarged.  Stools  are  brown-colored  ; 
likewise  the  urine  ;  the  latter  contains  traces  oi^  bile  coloring 
matter,  but  no  albumin  and  no  sugar.  No  fever ;  pulse  regular, 
strong,  84  beats  to  the  minute. 

Diagnosis. —  Chronic  cholecystitis,  stone  in  the  cysticus. 

Operation  on  the  21.  i.  97.  Morphine-atropine-chloroform 
anaesthesia.  Longitudinal  incision  from  the  curvature  of  the  ribs 
downward  to  the  height  of  the  navel.  Opening  of  the  belly, 
immediately  there  shows  itself  the  tensely  filled  gall-bladder  ;  it 
is  adherent  to  the  omentum  and  duodenum.  The  adhesions  are 
separated,  then  puncture  of  the  gall-bladder.  70  ccm.  of  pure 
mucus  are  removed.  After  that  the  puncture  was  enlarged  by  a 
I  ^2  cm.  long  incision  ;  it  is  possible  with  a  dressing-forceps  to  re- 
move some  8  hazelnut-sized  stones.  At  the  neck  of  the  gall-blad- 
der 2  diverticula  had  developed,  and  in  them  lay  2  stones.  It  is 
impossible  to  press  these  into  the  real  gall-bladder,  therefore  in- 
cisions were  made  upon  them  and  they  were  removed.  A  stone 
about  the  size  of  a  bean  was  felt  in  the  cystic  duct ;  it  is  lodged  so 
firmly  in  the  w^alls  of  the  duct  that  it  must  also  by  an  incision  be 
removed  from  the  cystic  duct.  Both  incision  wounds  were  closed 
with  sutures.  After  that  one  had  convinced  himself  partly  by 
probing  and  partly  by  palpation  that  no  more  stones  were  to  be 
felt,  the  gall-bladder  was  stitched  to  the  parietal  peritoneum  ; 
then  partial  closure  of  the  abdominal  wound.     Introduction  of  a 


2o8  GALLSTONE  DISEASE. 

large  tube  into  the  gall-bladder.  Dressing.  Duration  of  the 
operation,  i  ^  hours.  The  course  was  absolutely  afebrile. 
Patient  did  not  vomit,  flatus  passed  after  48  hours.  Pulse  strong, 
80  beats  in  the  minute.  Still  there  is  never  bile,  only  mucus 
escaping.  The  probing,  which  is  repeated  at  each  change  of 
dressings,  never  detects  a  stone  in  the  gall-bladder.  It  is  there- 
fore assumed  that  the  cystic  duct  is  swollen  or  obliterated.  The 
healine  of  the  wound  advances  more  and  more,  the  mucous 
fistula  closed  so  that  the  patient  could  be  discharged  on  2.  3.  97 
cured.  The  patient  feels  always  well,  so  that  an  obliteration  of 
the  cystic  duct  must  be  assumed.  Cure  confirmed  at  the  end  of 
1898. 

(b)  Mrs.  T.,  53  years,  from  Zerbst.  Entered,  12.  7.  96. 
Operation,  14.  7.  96.  Cystostomy,  cystocotomy.  Closure  of 
biliary  fistula  with  opening  of  the  abdomen  (21.  9.  96).  Dis- 
charged, 3.  8.  96.     (3.  10.  96,  cured.) 

Patient  was  referred  to  the  clinic  by  her  son-in-law,  Dr.  Schiitz 
of  Berlin.  Patient  is  said  to  have  been  always  in  good  health 
until  5  years  ago.  About  that  time  occurred  vomiting,  consti- 
pation, feeling  of  pressure  in  the  region  of  the  gall-bladder. 
Jaundice  was  never  present.  In  5  years  there  occurred  3  attacks 
of  colic  of  several  hours'  duration.  On  account  of  her  suffering 
the  patient  went  four  times  to  Carlsbad,  whence  she  returned 
improved.  The  improvement  lasted  about  a  year  after  each  cure. 
Stones  were  never  passed.  Her  last  stay  in  May,  '96,  however, 
had  no  lasting  success  ;  since  already,  a  fortnight  later,  the  old 
distress  returned  again  with  its  usual  frequency.  The  stools  were 
always  brown,  the  urine  yellow.  The  patient  came  on  that  ac- 
count to  Halberstadt. 

Status  Prsesens. — Medium-sized,  powerfully-built  woman  ; 
no  jaundice.  Heart  and  lungs  normal.  The  liver  is  not  en- 
larged, there  is  sensitiveness  to  pressure  in  the  region  of  the 
gall-bladder.  There  is  an  egg-shaped  timior  to  be  felt,  which 
moves  up  and  down  with  the  respiration  and  is  very  movable. 
Enlargement  of  the  spleen  is  not  observed.     Temperature  nor- 


CLINICAL  AND  OPERATION  HISTORIES. 


209 


mal,  pulse  70  beats  to  the  minute,  regular  and  strong.  Stools 
are  brown  ;  urine,  light-yellow  color,  contains  neither  albumin, 
bile  coloring  matters  nor  sugar. 

Diagnosis. — Chronic  hydrops  of  the  gall-bladder.  Stone  in 
the  cystic  duct. 

Operation  on  the  14.  7.  Morphine-ether  anaesthesia.  Lon- 
gitudinal incision  in  the  right  rectus  abdominal  muscle.  Gall- 
bladder large  and  tensely  filled.  Adhesions  between  it  and  the 
pylorus  ;  separation  of  these.  The  gall-bladder  is  brought  out 
of  the  wound,  the  belly  protected  by  gauze  compresses.  With 
the  aspirator  dropsical  fluid  is  removed.  The  gall-bladder  is 
filled  with  six  stones  about  hazelnut  size.  In  the  cystic  duct 
there  is  a  tightly  wedged  stone.  Since  the  cystic  duct  is  very 
accessible  a  cystocotomy  is  performed.  Four  sutures  close  the 
wound.  Tube  in  the  gall-bladder.  Suture  of  this  to  the  parie- 
tal peritoneum.      Duration  of  the  operation  J^ths  of  an  hour. 

During  the  first  three  days  after  the  operation  slight  elevation 
of  temperature.  Afterwards  completely  afebrile  course.  Im- 
mediately on  the  first  day  bile  escapes.  Patient  recovers  quickly, 
is  discharged  to  her  home  already  on  the  3.  8.  96,  with  only  a 
slightly  secreting  biliary  fistula.  On  the  16.  9.  96  the  patient 
again  presents  herself;  the  biliary  fistula  has  not  yet  closed. 
Mrs.  T.  says  that  in  all  the  time  which  has  passed  since  her  dis- 
charge she  has  been  tortured  and  weakened  by  the  persistent 
escape  of  bile.  Once  she  is  said  to  have  been  jaundiced,  at  the 
same  time  also  had  occurred  distress  from  the  stomach  and  in- 
testines. The  attending  physician  had  diagnosticated  a  gastro- 
duodenal  catarrh.  Probing  of  the  gall-bladder  gives  a  negative 
result.  Employment  of  the  plugging  experiment  does  not  occa- 
sion any  feeling  of  pressure,  hence  it  is  inferred  that  the  ductus 
choledochus  is  free  from  stones.  The  escape,  therefore,  to  be 
explained  only  by  a  dragging  upon  or  kinking  of  the  chole- 
dochus. On  the  21.9,  therefore,  we  proceeded  to  separate  the 
gall-bladder  from  the  abdominal  wall.  In  so  doing  the  abdomi- 
nal cavity  is  opened  to  a  very  sHght  extent.     Suture  of  the  gall- 


2IO  GALLSTONE  DISEASE. 

bladder  after  necessary  revivification.  The  general  condition  of 
the  patient  after  this  operation  was  always  good  ;  there  were 
never  any  complaints  of  pressure.  Stools  were  brown,  the 
urine  clear  and  free  from  bile  coloring  matters.  The  sutures 
held  so  that  the  woman  could  now  be  discharged  as  cured. 

A  dropsy  m  a  contracted  gall-bladder  occurred  in  the  next 
case.  Mrs.  H.,  65  years,  wife  of  a  captain,  from  Erfurth.  En- 
tered, 16.  9.  96.  Oper.,  18.  9.  96  and  16.  10.  96.  Cystostomy  in 
two  stages  and  cystico-lithotripsy.  Discharged,  22.  11.96. 
Cured. 

Patient,  who  is  childless,  is  said  to  come  from  a  healthy 
family  and  herself  always  to  have  been  healthy.  In  the  spring  of 
1895  she  was  attacked  with  pains  in  the  stomach  and  vomiting. 
Jaundice  also  occurred.  Bowels  were  constipated,  stools  of 
brown  color,  only  at  the  time  of  the  jaundice  white.  The  phy- 
sician who  was  called  diagnosticated  gallstones,  and  advised  a 
stay  in  Carlsbad.  The  patient  went  thither.  After  a  six  weeks' 
cure  she  was  freed  from  her  pains,  and  so  remained  ^ths 
of  a  year.  Then  again  occurred  a  violent  attack.  Again 
the  health-giving  springs  of  Carlsbad  were  sought,  but  this 
time  with  sHght  success,  for  already  a  fortnight  after  the  com- 
pleted cure  the  old  pains  were  again  back  in  undiminished 
violence. 

Status  Praesens. — Small,  thin  woman.  Heart  and  lungs 
normal.  At  present  no  jaundice.  The  liver  is  not  enlarged  ;  in 
the  gall-bladder  there  exists  marked  sensitiveness.  No  tumor 
of  the  spleen.  Stools  are  brown,  urine  light-colored,  contains 
no  albumin,  sugar  or  biliary  coloring  matters.  Temperature  is 
normal,  pulse  regular,  of  moderate  strength,  74  beats  to  the 
minute. 

Diagnosis. — Stones  in  the  gall-bladder,  adhesions. 

Operation  on  the  18.  9.  96.  Morphine-atropine-chloroform 
anaesthesia.  Longitudinal  incision  in  the  right  rectus  abdominal 
muscle.  On  opening  the  belly  there  presented  the  small,  con- 
tracted gall-bladder  lying  high  up  under  the  liver.     On  attempt- 


CLINICAL  AND  OPERATION  HISTORIES.  2H 

ing  to  palpate  this,  pulse  and  breathing  stopped.  One  can  feel 
stones  in  the  gall-bladder.  The  patient,  however,  bears  the 
ancesthesia  so  ill  that  an  examination  of  the  deep  bile  ducts 
could  not  be  made.  To  sew  the  gall-bladder  into  the  wound  is 
impossible  on  account  of  its  smallness  and  the  rigid  peritoneum. 
The  heart  action  also  is  so  weak  that  the  operation  must  be 
ended.  Therefore  the  unopended  gall-bladder  was  stitched  to 
the  peritoneum  on  the  right,  the  rest  of  the  wound  tamponed 
and  in  part  closed.  Dressing.  Duration  of  the  operation,  ^ 
hour.  19.  9.  96.  Patient  has  vomited  very  little,  is  free  from 
fever.  Belly  is  soft  and  not  sensitive.  20.  9.  96.  With  glycer- 
ine the  first  flatus  passes  to-day.  Patient  feels  well.  No  fever. 
26.  9.  96.  Patient  the  whole  time  free  from  fever.  Since  now 
we  may  expect  the  abdominal  cavity  to  be  completely  shut  off, 
the  gall-bladder  is  opened  to-day  without  anaesthesia,  and  from 
it  are  removed  several  stone  fragments  together  with  viscid 
mucus.  A  thin  tube  was  introduced  into  the  fistula ;  then 
dressing.  Bile  does  not  flow.  Since  bile  does  not  escape  at  any 
change  of  dressings  and  fragments  of  stones  are  yet  constantly 
washed  out,  especially  since  with  the  probe  stones  are  to  be  de- 
tected deep  down,  which  in  spite  of  every  care  cannot  be  ex- 
tracted from  the  fistula,  one  proceeds  on  the  i6th  of  October 
again  to  operation.  Abdomen  opened  by  a  longitudinal  incision 
in  the  median  line  from  the  xyphoid  process  to  the  navel.  The 
examination  is  rendered  extraordinarily  difficult  by  the  numer- 
ous adhesions.  With  difficulty  it  is  possible  to  palpate  the  stone 
felt  in  the  transition  of  the  gall-bladder  into  the  cystic  duct,  and 
since  to  push  it  back  is  impossible,  a  cystocotomy  is  decided 
upon.  In  fixing  the  stone  for  the  incision  it  breaks  into  frag- 
ments. Therefore  we  have  an  involuntary  cystico-lithotripsy. 
The  fragments  are  removed  from  the  gall-bladder,  upon  which 
bile  escapes  immediately.  No  further  stones  to  be  felt.  Closure 
of  the  abdominal  wound.  Duration  of  the  operation,  i  hour. 
Patient  bore  the  procedure  well  ;  has  no  fever.  Ten  days  later 
dressing  changed.  The  sutures  were  removed  ;  reactionless  heal- 


212  GALLSTONE  DISEASE. 

ing.  Bile  in  the  dressings.  In  washing  out  the  gall-bladder  some 
small  fragments  of  stones  were  still  removed.  30.  10.  To-day 
the  flow  of  bile  suddenly  ceased  ;  only  mucus  escapes  from  the 
fistula.  With  the  probe  no  stone  is  to  be  felt ;  introduction  of  a 
laminaria  tent.  31.10.  Despite  the  dilated  fistula  no  stone  is  to 
be  detected.  Dressing.  22.  11.  Up  till  the  present  no  bile  has 
escaped.  Patient  is  discharged  with  the  fistula  completely 
healed. 

Probably  the  stone  had  caused  a  decubital  ulcer  (lithotripsy), 
which  in  healing  later  caused  an  obliteration  of  the  cystic  duct. 
At  all  events  the  mucous  fistula  dried  up  and  the  patient  enjoys 
the  best  of  health  according  to  recent  information. 

In  the  following  cases  there  occurred  a  complication  of  chole- 
lithiasis with  right-sided  movable  kidney  ;  in  order  to  arri\'e  at  the 
correct  diagnosis,  a  very  exact  palpation  is  necessary. 

(a)  Mrs.  B.,  29  years,  from  Konigerode.  Entered,  4.  i.  97. 
Operation,  6.  I.  97.  Cystostomy  and  cystocotomy.  Discharged, 
3.  2.  97.      Cured  (10.  2.  97). 

Patient,  mother  of  three  healthy  children,  is  said  to  come  of 
a  healthy  family,  and  herself  never  to  have  been  ill.  As  a  young 
girl  she  was  anemic.  Nine  years  ago  there  occurred  violent 
headaches  which  were  independent  of  her  menses.  They  be- 
came worse  if  she  worked,  better  upon  rest  in  bed.  During  this 
time  the  patient  complained  of  pains  in  the  stomach,  loss  of 
appetite,  vomiting,  besides  there  was  constipation.  Four  and  two 
years  ago  the  distress  mentioned  was  especially  violent.  At  that 
time  the  patient  noticed  the  appearance  of  a  tumor  in  the  region 
of  the  gall-bladder,  which  was  very  sensitive  to  pressure.  Jaun- 
dice is  said  never  to  have  existed.  Since  in  spite  of  the  internal 
medication  employed  no  improvement  occurred,  ~\\x?>.  B.  decided 
for  an  operation. 

Status  Prsesens. — ^Medium-sized  woman  of  moderately  good 
condition  of  nutrition.  Heart  and  lungs  normal.  No  jaundice. 
Liver  and  spleen  not  enlarged  ;  in  the  region  of  the  gall-bladder 
there  exists  sensitiveness  to  pressure,  besides  there  are  here  to 


CLINICAL  AND  OPERATION  HISTORIES.  21  3 

be  felt  two  different  sized  easily  movable  tumors,  of  which  the 
one  appears  to  have  the  form  of  the  lower  pole  of  the  kidney 
and  the  other  to  correspond  superficially  to  the  gall-bladder. 
The  stools  are  of  normal  color,  likewise  the  urine,  which  con- 
tains no  albumin,  no  sugar,  no  bile  coloring  matters.  The 
patient  is  free  from  fever,  the  pulse  regular,  strong,  84  beats  to 
the  minute. 

Diagnosis. — Stones  in  the  gall-bladder,  chronic  obstruction 
of  the  cystic  duct ;  right-sided  movable  kidney. 

Operation  on  the  6.  i.  97.  Morphine-atropine-chloroform 
anaesthesia.  Longitudinal  incision  in  the  right  rectus  abdom. 
muscle.  On  opening  the  abdomen  it  is  apparent  that  the  about 
pullet-egg-sized  gall-bladder  is  adherent  to  the  omentum  and 
intestine  by  numerous  adhesions.  After  that  the  gall-bladder  is 
completely  isolated,  somewdiere  about  20  ccm.  of  muddy  bile 
were  removed  from  it.  The  puncture  was  enlarged,  and  now  it 
is  possible  to  extract  with  forceps  10  hazelnut-sized  stones.  In 
spite  of  repeated  endeavors  it  is  impossible  to  push  into  the  gall- 
bladder a  stone  lodged  in  the  cystic  duct  and  thence  to  remove  it. 
Therefore  the  cystic  duct  is  opened  by  incision,  the  stone  pressed 
out,  and  immediately  thereupon  the  incision  is  closed  with  a 
double  row  of  sutures.  Since  no  more  stones  are  to  be  detected, 
the  gall-bladder  is  sutured  to  the  peritoneum  and  the  abdominal 
walls  in  part  closed  with  sutures.  Introduction  of  a  tube  into 
the  gall-bladder.  Dressing.  Duration  of  the  operation,  i  J^ 
hours.  The  operative  treatment  of  the  movable  kidney  which 
was  confirmed  after  the  opening  of  the  abdomen  was  renounced, 
since  the  view  was  confirmed  that  the  distress  of  the  patient 
could  be  caused  indeed  by  the  gallstones  alone.  Immediately 
after  the  operation  bile  escaped.  Normal  wound  history.  On 
the  3.  2.  the  patient  is  discharged  with  a  slightly  secreting  biliary 
fistula.  Complete  closure  of  the  fistula  10.  2.  97.  The  patient 
on  the  1 .  9.  98  presents  herself  again  and  complains  of  distress 
(pains  in  the  stomach,  nervousness,  etc.).  The  scar  over  the 
gall-bladder    shows    no    sensitiveness    to  pressure.     The    right 


214  GALLSTONE  DISEASE. 

kidney  is  vety  movable,   on   reposition  somewhat  painful.     A 
suitable  bandage  is  prescribed. 

Often  patients  complain  :  **  The  gallstone  operation  has  not 
been  of  much  service,  I  still  have  constant  distress."  This  is 
especially  true  of  the  cases  in  which  the  cholelithiasis  previously 
was  complicated  with  other  diseases,  as  by  wandering  kidney, 
ulcer  of  the  stomach,  adhesive  peritonitis.  In  such  cases  we 
will  not  attain  ideal  results  except  by  veiy  early  treatment,  and 
uncomplicated  cases  we  can  restore  to  normal  conditions. 

(b)  Mrs.  F.  B.,  26  years,  wife  of  a  postillion,  from  Wernige- 
rode.  Entered,  14.  i.  99.  Operation,  15.  1.99.  Cystectomy, 
choledochotomy.      Discharged,  15.  2.  99.      Cured. 

Amnesis. — Parents  of  Mrs.  B.  are  living,  mother  is  healthy, 
father  suffers  from  rheumatism.  Mrs.  B.,  formerly  healthy, 
married  at  21  years  old,  mother  of  3  children,  of  which  two  are 
living  and  healthy.  The  present  illness  began  2  years  ago  and 
showed  itself  by  piercing  pains  in  the  right  upper  region  of  the 
abdomen,  pain  in  pit  of  the  stomach,  constipation,  pains  in  the 
back.  Patient  declares  she  often  has  attacks  of  sticking  pain  in 
the  right  upper  part  of  the  abdomen  ;  recently  walking  and  sitting, 
especially  bending,  are  felt  very  disagreeably  in  the  right  side  of 
the  abdomen.      The  appetite  was  bad. 

Status  Praesens. — Medium-sized,  feeble,  pale  woman  of  poor 
condition  of  nutrition.  Urine  free  from  albumin,  sugar  and  bile 
coloring  matters.  Tumor  of  the  gall-bladder  to  be  felt.  Nearly 
to  the  right  a  second  tumor,  which  clearly  shows  the  plumping 
back  of  a  wandering  kidney. 

Diagnosis. — Right-sided  wandering  kidney.  Acute  dropsy 
of  the  gall-bladder. 

Operation,  15.  i.  Longitudinal  incision  in  the  right  rectus 
muscle.  Gall-bladder  large,  no  adhesions.  Aspiration  of  muco- 
purulent secretion.  In  the  cystic  duct  is  a  small  stone,  which 
on  palpation  slips  into  the  choledochus.  Choledochotomy. 
Suture  with  3  sutures  of  catgut.  In  the  gall-bladder  2  large 
and  several  smaller  stones.      Cystectomy.     Tamponade.     Suture 


CLINICAL  AND  OPERATION  HISTORIES.  21  5 

of  the  abdominal  wound.  Right-sided  wandering  kidney  is  left 
untouched.  A  gland  on  the  cystic  duct  caused  great  difficulties  ; 
the  gland  was  as  hard  as  if  a  stone  was  concealed  therein.  In 
fact  this  was  the  case.  It  slipped  into  the  choledochus.  Smooth 
afebrile  course.  Dressing  dry.  Good  general  condition.  On 
the  14th  day  first  dressing.  Wound  in  order.  Discharged  cured 
on  the  I  5.  2.  99. 

TJie  cojiibination  of  right-sided  JiydroncpJirosis  zvith  an  inflamed 
gall-bladder  I  have  seen  only  once  in  the  following  case  : 

Mrs.  W.,  38  years,  wife  of  a  hotel-keeper,  from  Stendal. 
Entered,  21.  i.  97.  Operation,  23.  i.  97,  6.  3.  97  and  13.  3.  97, 
Cystotomy,  twice  closure  of  fistulae.  Discharged,  16.  4.  97. 
Cured. 

Patient  passed  through,  at  the  ages  of  12  and  16  years,  scarlet 
fever  and  typhoid.  Her  present  distress,  which  consists  of  vomit- 
ing, constipation,  feeling  of  fullness,  pains  in  the  back,  dates  from 
the  year  1878.  Her  distress  became  worse  in  1887,  and  on  this 
account  she  visited  Carlsbad  for  relief  A  four  weeks'  cure  there 
freed  her  for  about  a  year  from  her  pains.  At  that  time  she  no- 
ticed for  the  first  time  a  tumor  in  the  region  of  the  gall-bladder ; 
this  disappeared,  but  again  appeared  in  the  year  1891  during  a 
new  attack.  Again  Carlsbad  brought  relief,  and  it  was  for  a 
space  of  two  years.  Then,  however,  the  old  trouble  began.  A 
slight  pain  on  pressure  would  not  yield,  from  time  to  time  vomit- 
ing, the  stools  were  very  irregular.  In  November,  1896,  the 
pains  were  especially  severe,  so  that  the  patient  decided  for 
operation.  Jaundice  during  the  entire  duration  of  the  disease 
had  never  appeared.  Any  sort  of  an  irregularity  in  the  passage 
of  urine  was  denied.  In  the  year  1891  a  physician  who  had 
been  called  diagnosticated  right-sided  hydronephrosis. 

Status  Prsesens. — Powerfully-built,  medium-sized  woman. 
Heart  and  lungs  normal.  No  jaundice.  In  the  region  of  the 
gall-bladder  an  egg-shaped  tumor  is  to  be  felt,  which  moves 
with  the  respiration.  The  tumor  has  a  smooth  upper  surface 
and  of  tense-elastic  consistence  ;  above  it  passes  over  into  the 


2l6  GALLSTONE  DISEASE. 

liv^er  ;  its  lower  pole  is  at  the  level  of  the  navel.  Moreover,  the 
right  kidney  is  easy  to  palpate  ;  its  lower  part  feels  tense  and 
broadened.  The  urine  contains  no  abnormal  constituents  ;  in 
24  hours  1250  ccm.  are  eliminated.  Stools  are  brown-colored; 
in  them  no  stones.  Temperature  37.5°  in  evening;  pulse  86°, 
regular  and  strong. 

Diagnosis. — Chronic  cholecystitis.  Stones  in  the  gall-bladder 
and  in  the  cystic  duct ;  perhaps  in  addition  right-sided  hydrone- 
phrosis. 

Operation  on  the  23.  i.  97.  Morphine-atropine-chloroform 
anaesthesia.  Longitudinal  incision  in  the  right  rectus  muscle. 
On  opening  the  belly  there  appears  the  tense-filled  gall-bladder  ; 
it  is  not  adherent  with  its  surroundings.  Protection  of  the 
abdominal  cavity  by  compresses  ;  puncture  of  the  gall-bladder  ; 
thus  were  about  80  ccm.  of  bilious  mucus  removed.  The 
fundus  of  the  gall-bladder  is  then  incised  for  1 1^  cm.,  and  with 
forceps  it  is  possible  to  remove  20  hazelnut-sized  stones.  A  stone 
lodged  in  the  cystic  duct  is  pushed  into  the  gall-bladder  and 
then  extracted.  Beneath  the  gall-bladder  lies  a  retroperitoneal 
cystic  tumor  the  size  of  an  apple.  It  passes  over  into  right 
kidney  (hydronephrosis).  An  operation  is  abstained  from.  The 
left  kidney  lies  in  its  proper  position  and  is  of  normal  size.  The 
gall-bladder  is  stitched  to  peritoneum,  through  which  latter  the 
sutures  repeatedly  tear.  Partial  closure  of  the  abdominal  wound. 
Duration  of  the  operation,  i  i^  hours. 

The  course  was  completely  afebrile.  On  the  second  day  bile 
flowed.  After  3  weeks  the  patient  left  her  bed.  The  wound 
granulates  well.  The  biliary  fistula,  howev^er,  would  not  close  ; 
almost  daily  must  the  patient  be  dressed.  For  this  reason  it  was 
decided  to  free  the  gall-bladder  from  the  parietal  peritoneum  and 
to  close  it  with  sutures.  To  avoid  general  anaesthesia,  Schleich's 
local  anaesthesia  on  the  6.  3.  97.  The  separation  with  difficulty 
succeeds  ;  on  suturing  the  stitches  cut  out  repeatedly.  On  the 
succeeding  day  the  dressing  is  soaked  with  bile.  On  the  13.  3., 
under  chloroform  anaesthesia,  the  gall-bladder  is  again  dissected 


CLINICAL  AND  OPERATION  HISTORIES.  21/ 

free,  by  which  the  abdominal  cavity  is  opened  only  in  a  small 
spot,  the  torn  edges  are  removed,  and  an  exact  suture  now  car- 
ried out.  This  time  the  stitches  hold,  so  that  on  the  i6.  4.  97 
she  could  be  discharged  for  her  home  cured. 

The  hydronephrosis,  as  an  examination  at  the  beginning  of 
this  year  shows,  has  not  materially  increased  ;  troubles  are  no 
longer  present,  so  that  I  at  the  present  could  advise  against 
operative  treatment  of  the  hydronephrosis.  The  woman  looks 
glowing  and  healthy,  has  increased  about  20  pounds  in  weight, 
and  can  direct  and  manage  in  her  hotel  as  never  heretofore. 
She  is  very  content  with  the  success  of  the  operation.  In  the 
following  case  one  at  first  thought  of  an  intermittent  Jiydrone- 
phrosis.  The  palpated  tumor  was,  however,  the  right  lobe  of  the 
liver ;  the  troubles  of  a  movable  liver  were  certainly  increased 
by  the  gallstones  which  were  present.  Near  by  was  a  right- 
sided  movable  kidney. 

A.  D.,  44  years,  wife  of  a  painter,  from  Hotensleben.  En- 
tered, 10.  10.  98.  Operated  upon,  12.  10.  98.  Cystectomy, 
hepatopexy.      Discharged,  13.  11.  98.      Cured. 

The  patient  sought  the  clinic  at  the  suggestion  of  Dr.  Dietrich 
of  Madgeburg  and  Dr.  Strube  of  Hotensleben.  She  complains 
of  pain  in  the  right  side,  cramps  in  the  stomach,  difficult  urina- 
tion. The  tumor,  which  she  feels  in  the  region  of  the  liver,  often 
changes  its  size  ;  if  it  is  small  then  the  patient  makes  always 
much  urine.  Jaundice  never  existed,  appetite  poor,  she  refers 
all  distress  to  the  stomach. 

Physical  Condition. — Spare,  suffering  woman.  Heart  and 
lungs  healthy.  Stomach  somewhat  low.  Urine  free  from  sugar, 
albumin  and  biliary  coloring  matters.  In  the  right  hypochon- 
drium  a  tense-elastic  tumor,  which  extends  from  the  curve  of  the 
ribs  almost  to  the  crista  ant.  ilei.  The  tumor  is  soft,  movable, 
moderately  painful,  follows  the  respiration  either  not  at  all  or 
only  very  little.  The  dullness  of  the  liver  passes  into  that  of 
the  tumor.  It  does  not  allow  itself  to  be  pushed  upward,  but 
well  backward  and  a  little  toward  the  median   line.     At  first  an 


2l8  GALLSTONE  DISEASE.  , 

intermittent  hydronephrosis  was  thought  of.  A  distension  of  the 
colon  with  air  shows  that  the  transverse  colon  hes  against  the 
lower  border  of  the  tumor.  In  narcosis  it  is  apparent  that  the 
tumor  is  still  very  movable,  especially  does  it  allow  motion  side- 
ways. If  one  presses  it  into  the  depths,  then  it  came  always  to  the 
surface.  We  left  the  diagnosis  in  suspense,  the  symptoms  were 
those  of  general  enteroptosis,  yet  we  had  the  impression  that  it 
is  better  to  clear  up  the  subject  by  approaching  it  from  in  front. 
Operation  on  the  12.  10.  98.  Longitudinal  incision  in  the 
right  rectus  from  the  curve  of  the  ribs  downward  to  the  extent 
of  12  cm.  On  opening  the  abdomen  the  formerly  palpated 
tumor  is  recognized  as  the  right  lobe  of  the  liver,  of  which  the 
lower  border  reaches  below  the  navel.  The  liver  is  easily  shoved 
back  into  the  dome  of  the  diaphragm,  but  falls  back  on  letting 
up  the  pressure.  The  gall-bladder  extends  i  ^  cm.  beyond  the 
liver  border  and  is  adherent  to  the  omentum  at  the  fundus.  After 
the  separation  of  adhesions,  which  succeeds  without  bleeding, 
the  system  of  the  bile  ducts  can  be  inspected  in  admirable  man- 
ner ;  the  choledochus  is  free  from  stones,  the  pancreas,  which 
owing  to  the  general  enteropsis  is  very  accessible  to  palpation, 
is  normal.  In  the  cystic  duct  near  its  opening  into  the  chole- 
dochus there  is  wedged  a  small  angular  stone.  It  is  impossible 
to  move  this.  One  would  have  been  obliged  to  get  it  out  to  do 
a  cystocotomy.  But  the  cystectomy  was  preferred  as  the  more 
suitable  procedure.  Taking  into  consideration  changes  in  the 
walls  of  the  gall-bladder,  likewise  the  high  grade  of  wandering 
liver,  the  operation  must  be  very  easy.  The  ectomy  was  under- 
taken in  this  manner,  that  first  the  cystic  duct  was  surrounded 
by  a  catgut  ligature  on  a  needle  and  tied  ;  moreover  the  arteria 
cystica  was  also  separately  ligated.  Then  the  bladder  was  sepa- 
rated from  the  liver  without  marked  bleeding.  The  stump  of  the 
cystic  duct  was  stitched  over  with  fine  catgut.  The  fossa  vesicae 
felleae  was  closed  as  far  as  possible  by  deep  sutures  of  thick 
catgut,  and  in  this  manner  the  bleeding  was  almost  absolutely 
controlled.     The   movable   liver  was  so  pressed  back  into  the 


CLINICAL  AND  OPERATION  HISTORIES.  219 

dome  of  the  diaphragm  that  it  again  occupied  its  normal  posi- 
tion, and  in  this  it  was  retained  by  six  thick  catgut  sutures  which 
fixed  the  anterior  border  of  the  right  lobe  of  the  liver  to  the 
parietal  peritoneum  and  fascia.  For  security  w^ere  further  two 
deep  sutures  of  this  catgut  passed  around  the  cartilage  of  the 
loth  rib.  Now  the  liver  no  longer  left  its  position.  Long 
strips  of  gauze  were  introduced  down  to  the  stump  of  the  cystic 
duct  and  to  the  liver  bed  and  the  abdominal  wound  closed  with 
through  and  through  silk  interrupted  and  skin  sutures  as  far  as 
the  exit  of  the  gauze  tampon  immediately  under  the  curvature 
of  the  ribs.      Dressing. 

Condition  of  the  Gall-Bladder. — The  gall-bladder  shows 
thick,  firm  w^alls.  The  contents  in  spite  of  the  apparently  so 
complete  obstruction  of  the  cystic  duct  consist  of  clear  light 
bile  and  6  soft  yellow  stones,  5  of  about  pea-size  and  one  of 
more  than  hazelnut  size,  which  is  lodged  in  the  neck.  No 
changes  in  the  mucous  membrane.  Course  afebrile.  Patient 
gets  up  the  3.  1 1.  and  feels  very  well. 

Remarks. — The  statement  of  the  patient  that  the  tumor  often 
changed  its  size,  and  that  then  urine  was  passed  in  abundance, 
led  us  to  the  diagnosis  of  an  intermittent  hydronephrosis.  Yet 
there  was  only  a  wandering  liver.  The  tumor  did  not  follow 
the  movements  of  the  diaphragm,  it  felt  tensely  elastic,  was 
spherical  and  soft ;  under  anaesthesia  we  were  puzzled  by  the 
great  mobility,  especially  the  lateral  mobility  led  us  to  assume 
that  a  tumor  of  the  liver  must  still  be  present,  so  that  we  made 
our  incision  in  front.  We  had  to  do  with  a  general  enteroptosis, 
dislocated  liver  with  gallstones.  The  excision  was  child's  play, 
since  the  whole  biliary  system  could  be  actually  made  extra 
peritoneal.  In  10  minutes  the  ectomy  was  completed.  The 
hapatopexy  was  insured  by  the  passage  of  the  thick  catgut  sutures 
(formalin  catgut)  about  the  cartilage  of  the  loth  rib,  and  by  the 
introduction  of  an  extensive  tampon  of  the  under  surface  of  the 
liver.  Very  excellent  afebrile  course.  Discharged  on  the  13. 
1 1.  98.      Cured. 


220  GALLSTONE  DISEASE. 

7- 
Empyema  Chronicum  Cystidis  Felleae. 

Mrs.  A.  P.,  60  years,  widow,  from  Dessau.  Entered  on  the 
4.  12.  98.  Operation,  5.  12.  98.  Atypical  ectomy.  Dis- 
charged, 22,  I.  98.      Cured. 

Amnesis. — Family  history  has  nothing  of  note.  Mrs.  P.  was 
healthy  until  3  years  ago  ;  about  once  a  year  a  cramp  of  the 
stomach  occurred.  Two  years  ago  jaundice  appeared  with  it.  In 
June,  1898,  an  extremely  violent  attack  occurred,  which  held  on 
about  a  day  and  was  followed  by  jaundice.  In  a  fortnight  the  jaun- 
dice and  the  pains  had  passed.  Gallstone  disease  was  diagnosti- 
cated. A  tumor  was  detected  under  the  curvature  of  the  ribs 
on  the  right.  The  stomach  was  very  sensitive.  Jaundice  per- 
sisted. Mrs.  A.  P.  is  emaciated  and  has  constant  pressure  in 
the  upper  abdominal  region  on  the  right.  An  authority  in  in- 
ternal medicine  advised  against  operation. 

Status  Prsesens. — Medium-sized,  not  icteric,  pretty  well  nour- 
ished woman.  Organs  healthy.  In  the  right  upper  abdominal 
region  an  indistinctly  definable  tumor  to  be  palpated,  which  is 
taken  to  be  the  adherent  gall-bladder.      Urine  normal. 

Diagnosis. — Stones  in  the  gall-bladder.  Empyema.  Ad- 
hesions. 

Operation. — Chloroform  anaesthesia.  15  cm.  longitudinal 
incision  in  the  right  rectus  muscle.  Omentum  adherent  to  the 
right  lobe  of  the  liver,  so  that  the  gall-bladder  is  concealed. 
On  separation  of  the  adhesions  to  the  liver  border  in  the  region 
of  the  gall-bladder  a  dark  gallstone  about  hazelnut-size  soon 
appears.  On  further  search  a  second  stone  and  pus  is  brought 
up,  which  latter  is  immediately  wiped  away.  Now  a  perforation 
is  seen  in  the  gall-bladder  from  which  a  similar  3d  stone  is  ex- 
tracted, whilst  the  removal  of  a  fourth  only  succeeds  in  frag- 
ments. Bile  escapes.  The  probe  detects  no  more  stones.  Ex- 
cision of  the  very  fragile  gall-bladder  at  the  level  of  the  neck. 
Introduction  of  a  tube  into   the   stump,  which  is  firmly  sutured. 


CLINICAL  AND  OPERATION  HISTORIES.  221 

Tamponade.  Closure  of  the  lower  part  of  the  wound  by 
through  and  through  interrupted  and  skin  sutures.  Duration, 
40  minutes. 

Smooth  Course. — Slight  escape  of  bile.  Fistula  in  the  mid- 
dle of  January  firmly  closed.  I^xcellent  general  condition.  Dis- 
charged cured. 

Empyema  and  dropsy  do  not  ahcays  admit  of  differentiation 
from  one  anotlier  since  even,  as  the  following  case  proves,  in  sup- 
puration of  the  gall-bladder  fever  and  marked  sensitiveness  to 
pressure  may  not  exist. 

Mrs.  L.,  36  years,  wife  of  a  director,  from  Wilhelmshall.  En- 
tered, 10.  6.  96.  Operation,  12.  6.  96  and  21.9.  96.  Cystos- 
tomy.    Fistula  closure.    Discharged,  8.  8.  96.    Cured  (11.  10.  96)^ 

Patient,  the  mother  of  four  healthy  children,  was  referred  to 
the  clinic  by  Dr.  Felber  from  Dingelstedt.  She  is  said  to  come 
from  a  healthy  family,  and  to  have  never  been  ill  until  her  present 
trouble,  which  consists  of  cramps  in  the  stomach,  vomiting, 
painfulness  in  the  region  of  the  gall-bladder  and  feeling  of  dis- 
tension. For  the  first  time  these  occurred  in  the  patient's  i8th 
year  ;  at  all  events  not  with  their  present  violence.  Jaundice  is 
said  to  have  never  existed.  The  stools  were  irregular,  usually 
constipated,  always  brown  ;  urine  was  of  yellow  to  red  color. 
Especially  violent  was  the  trouble  in  February,  1896.  The  at- 
tacks were  repeated  almost  daily,  so  that  the  nutrition  of  the 
patient  became  more  and  more  impaired.  About  this  time  the 
stools  were  at  times  grey,  and  the  urine  brown. 

Status  Prsesens. — Medium-sized  w^oman  of  pretty  good  con- 
dition of  nutrition.  No  jaundice  exists.  Heart  and  lungs  nor- 
mal. Gall-bladder  region  sensitive  to  pressure,  there  is  there  to 
be  felt  an  egg-shaped  tumor  of  firm  consistence  and  smooth 
upper  surface,  which  moves  with  the  respiration.  The  lower 
border  of  the  tumor  is  3  finger-breadths  abov^e  the  navel.  Spleen 
is  not  enlarged.  No  fever ;  the  pulse  is  regular,  strong,  6^ 
beats  to  the  minute.  The  stools  are  brown,  the  urine  yellow 
and  contains  neither  biliary  coloring  matters,  albumin,  nor  sugar. 


222  GALLSTONE  DISEASE. 

Diagnosis. — Dropsy  of  the  gall-bladder,  stone  in  the  cystic 
duct.  Operation  on  the  12.  6.  96.  Morphine-atropine-chloro- 
form  anaesthesia.  Longitudinal  incision  in  the  right  rectus 
muscle.  On  opening  the  belly  there  presents  the  tensely-filled 
gall-bladder  and  the  sharp  liver  border  drawn  out  on  it.  The 
gall-bladder  is  adherent  by  broad  adhesions  to  the  omentum  and 
duodenum.  Separation  of  adhesions.  Puncture  of  the  gall- 
bladder ;  by  this  there  was  removed  about  60  ccm.  of  pus.  In 
the  gall-bladder  and  in  the  cystic  ducts  stones  to  be  felt ;  these 
are  removed  Avith  forceps.  Suture  of  the  gall-bladder  to  the 
peritoneum.  Special  peritoneal  suture.  Partial  closure  of  the 
abdominal  wound.  Introduction  of  a  thick  tube.  Duration  of 
the  operation  one  hour. 

13.  6.  96.     No  fever;  patient  feels  well;  bile  flows. 

14.  6.  96.  Feels  well;  flatus  passes,  but  no  more  bile  flows. 
16.  6.  96.  In  the  bottle  there  is  about  50  ccm.  of  bile.  Patient 
is  free  from  fever  and  feels  completely  well.  Flatus  passes. 
Belly  is  soft,  not  sensitive.  17.  6.  96.  After  castor  oil  free 
evacuation  of  the  bowels — brown  color.  No  fever.  Mrs.  L. 
obtains  to-day  light,  solid  food.  22.  6.  96.  Change  of  dressings. 
Gall-bladder  is  well  adherent.  The  abdominal  sutures  are  re- 
moved. Those  between  the  gall-bladder  and  peritoneum,  how- 
ever, not ;  they  are  intended  to  be  thrown  off  of  themselves. 
26.  6.  96.  The  patient  left  her  bed  for  a  short  time  for  the  first. 
Her  condition  is  excellent.  2.  7.  96.  Patient  up  till  now  has 
had  to  be  dressed  3  times  ;  suture  not  yet  thrown  off  Consid- 
erable bile  escapes.  The  stools  look  light.  No  biliary  coloring 
matters  to  be  detected  in  the  urine.  8.  8.  96.  Patient  is  dis- 
charged from  the  clinic  ;  bile  still  constantly  escapes  ;  all  the 
sutures  except  3  have  separated. 

On  the  18.9.96  patient  again  presents  herself  Escape  of 
bile  has  not  ceased.  Mrs.  L.  must  almost  daily  have  the  dress- 
ings changed.  General  condition  good.  Stools  are  brown- 
colored.  Urine  contains  no  coloring  matters.  After  the  employ- 
ment of  the  plugging  experiment  no  feeling  of  pressure  develops, 


CLINICAL  AND  OPERATION  HISTORIES.  223 

hence  the  mference  is  justified  that  the  ductus  choledochus  is 
patent.  Therefore  on  the  21.  9.  96  the  separation  of  the  gall- 
bladder from  the  anterior  abdominal  wall  is  undertaken,  in  doing 
which  the  abdominal  cavity  is  opened  in  a  small  place  ;  the  gall- 
bladder is  closed  with  sutures.  Tamponade.  Course  is  in  every 
way  favorable  :  the  sutures  have  held  ;  no  complaint  of  pain 
on  pressure.  The  patient,  therefore,  is  discharged  in  the  best  of 
health  from  the  clinic  on  the  11.  10.  96. 

TJic  transition  of  cJiolelithiasis  from  a  latent  to  an  active  condi- 
tion through  the  infliience  of  a  trauma  is  by  no  means  a  rare 
occurrence.  The  following  case,  which  deals  with  a  case  of 
suppuration  in  a  gall-bladder  which  lay  high  up  under  the  liver 
and  was  not  to  be  palpated,  may  serve  as  a  proof  of  this  : 

Dr.  H.,  52  years,  from  Dresden.  Entered,  13.  12.98.  Opera- 
tion, 15.12.  Cystostomy  with  partial  attachment.  Discharged, 
27.  I.  99,  with  biliary  fistula. 

Amnesis. — The  history  the  patient  himself  had  the  kindness 
to  write  down.  It  says  :  *'  Hereditary  conditions  :  father  died 
at  76  years  old  ;  mother  is  living  at  80  in  good  health.  Of 
brothers  and  sisters  8  live  in  good  health,  one  died  at  8  years  of 
valvular  disease  of  the  heart.  As  child  I  have  suffered  in  mod- 
erate des^ree  from  rachitis  and  scrofulous  eczema.  Afterwards 
strong  and  healthy.  In  1878  an  insufficiency  of  the  mitral  de- 
veloped very  gradually,  which  was  diagnosticated  by  Professor 
Wagner  of  Leipzig  and  Geheimrat  Dr.  Fiedler  of  Dresden. 
Compensation  at  present  is  good,  despite  great  profession  labor. 
In  the  last  6  or  8  years,  periodically  at  intervals  of  6  to  8  weeks, 
stomach  disturbances  from  excessive  acidity  and  atony  of  the 
stomach,  especially  after  certain  foods,  as  onions.  These  attacks 
lasted  only  several  hours ;  after  vomiting  the  last  taken  food  as 
an  excessively  acid  mass  complete  well  feeling  returned.  Appe- 
tite before  and  after  normal.  Defecation  always  normal  and 
regular.  On  the  loth  of  October,  in  the  evening  about  6  o'clock, 
I  was  run  into  by  a  cyclist  and  thrown  to  the  ground.  The  blow 
involved  the  region  of  the   chest.     At  first  absolutely  no  painful 


224  GALLSTONE  DISEASE. 

sensation;  on  next  evening  at  lo  o'clock,  however,  first  attack 
of  violent  pains,  which  set  in  gradually,  then  they  appeared 
boring,  flowing  and  ebbing,  and  localized  in  the  situation  of  the 
gall-bladder.  Duration,  1-2  hours.  With  these,  as  formerly, 
acid  vomiting  and  nausea.  These  attacks  since  have  recurred 
with  pauses  of  1-3  days,  mostly  2  days,  with  painful  regularity 
at  the  same  evening  hour  ;  while  gradually  vomiting  has  ceased 
during  these,  they  have  gradually  been  characterized  as  attacks 
of  pure  pain.  During  some  I  have  taken  at  last  morphine  injec- 
tions 0.0 1  for  relief.  In  the  intervals  there  was  usually  a  com- 
pletely normal  state,  good  appetite  and  regular  normal  defeca- 
tion. Jaundice  was  wanting.  Urine  free  from  albumin,  sugar 
and  biliary  coloring  matters." 

Diagnosis  of  acute  inflammation  of  the  gall-bladder  was  made 
— a  contracted  gall-bladder.  Tumor  not  to  be  felt.  A  blowing 
systolic  murmur  in  heart.      Other  organs  healthy. 

Operation  on  the  15.  12.  At  first  chloroform,  and  then,  on 
account  of  poor  respiration  and  heart  action,  ether.  Longi- 
tudinal incision  in  the  right  rectus  muscle.  Gall-bladder  small, 
very  tensely  distended,  lies  far  to  the  right,  and  extremely  high 
up  under  the  liver.  No  adhesions  ;  a  stone  in  the  cystic  duct. 
Resection  of  the  curvature  of  the  ribs  after  Lannelongue,  in 
order  especially  to  bring  the  gall-bladder  to  view.  Aspiration 
of  purulent  fluid  (bacterium  coli  demonstrated).  In  the  cystic 
duct  a  stone  ;  permits  itself  to  be  pressed  into  the  gall-bladder. 
Extraction.  Suture  of  the  gall-bladder  to  the  parietes  only  par- 
tially succeeds.  Tamponade  of  the  belly  at  the  under  surface 
of  the  gall-bladder  with  sterile  gauze.  A  very  difficult  operation 
lasting  two  hours.  Pulse  small,  120.  Patient  raves  and  storms 
in  bed,  it  is  scarcely  possible  to  restrain  him.  Evening  temp., 
37.2°  ;  pulse,  130.  No  vomiting.  The  pulse  becomes  slower 
and  better.  Temperature  always  normal.  Escape  of  bile  in 
profuse  quantity  begins  on  the  4th  day  after  the  operation.  On 
the  1 2th  day  after  the  operation  dressings  changed  and  tampon 
removed.  Wound  looks  well.  In  January  no  more  bile  escapes 
from  the  still   accessible  gall-bladder,  but  only  a  little  mucus. 


CLINICAL  AND  OPERATION  HISTORIES.  225 

Therefore,  it  was  attempted  to  keep  the  gall-bladder  open  some- 
what longer  so  as  to  be  able  to  remove  any  stone  that  might 
remain  behind.  The  gall-bladder  is  constantly  plugged  with 
sterile  gauze.  Stone  not  detected.  Two  days  before  discharge 
there  is  bile  in  the  dressing.  General  feeling  admirable.  Sleep, 
appetite  and  stools  good.  Discharged  on  the  27.  i.  99,  with 
biliary  fistula.     After-treatment  in  Dresden. 

Remarks. — Very  noteworthy  is  the  occurrence  of  the  colics 
after  the  accident  pictured  by  the  colleague  (knocked  down  by  a 
cyclist).  The  injury  plays,  as  I  often  enough  will  remark,  in 
the  transition  of  the  cholelithiasis  from  a  latent  to  an  active 
stage  a  very  important  role,  and  we  surgeons  have  every  reason, 
in  the  cases  of  artisans  who  fall  ill  with  gallstones,  to  give  atten- 
tion to  the  influence  of  previous  accidents.  Lannelongue's  re- 
section of  the  cartilage  of  the  ribs,  to  give  better  access  to  a 
concealed  gall-bladder,  is  seldom  necessary — and  almost  only 
in  men  in  whom  the  gall-bladder  very  frequently  lies  very  high 
up.  If  one  can  avoid  the  resection  of  the  rib  cartilages,  then 
the  procedure  is  much  less  complicated.  The  empyema  which 
occurred  in  this  case  was  difficult  to  diagnosticate,  since  the  gall- 
bladder, of  course,  could  not  be  palpated.  It  is  a  remarkable 
occurrence  that  within  the  course  of  a  year  I  operated  upon  3 
Dresden  colleagues  who  were  ill  with  the  same  form  of  chole- 
lithiasis, namely,  an  acute  cholecystitis,  and  wonderful  to  relate, 
there  was  in  each  of  the  3  patients  only  a  single  stone  in  the 
neck  of  the  gall-bladder  or  in  the  cystic  duct.  For  the  Dresden 
gallstone  patients  the  colleagues  are  an  example  in  their  decision 
for  an  operation. 


8. 

Carcinoma  of  the  Gall-Bladder. 

A  case  in  which  it  was  easy  to  diagnosticate  carcinoma  of  the 
gall-bladder  was  the  following.      It  is  so  far  typical,  as  most  car- 
19 


226  GALLSTONE  DISEASE. 


cinomata  first  come  under  observation  of  the  surgeon  at  a  period 
in  which  an  operation  is  impossible. 

S.,  6^  years,  wife,  from  Harsleben.  Entered,  7.  3.  98.  Open, 
II.  3.  98.  Laparotomia  explorativa  (carcinoma).  Discharged, 
17.  3.  98.     UnreHeved. 

Amnesis. — Mrs.  S.  is  deaf,  and  therefore  it  is  almost  impos- 
sible to  get  a  history  of  her  disease.  Apparently  the  patient  in 
recent  times  has  complained  of  pain  in  the  region  of  the  stomach, 
loss  of  appetite  and  loss  of  flesh.  Colics  are  said  to  have  ex- 
isted for  many  years.    Dr.  Hammer  sent  the  patient  for  operation. 

Status  Prsesens. — Small,  spare,  very  icteric  woman  ;  emphy- 
sema of  lungs,  heart  enlarged  towards  the  right,  arterio-sclerotic 
pulse  74  and  regular.  Liver  markedly  enlarged,  gall-bladder 
to  be  felt  as  an  irregular,  hard  tumor.  Pain  on  pressure  in  the  re- 
gion of  the  gall-bladder.  The  diagnosis  is  made  with  positive- 
ness  of  cancer  of  the  gall-bladder ;  an  operation  refused  ;  the 
relatives  wished  to  leave  nothing  undone,  and  wished  urgently 
an  exploratory  operation. 

Operation. — Chloroform  anaesthesia.  Opening  of  the  abdo- 
men by  a  6  cm.  longitudinal  incision  in  the  right  rectus  muscle. 
Liver  very  much  enlarged,  its  lower  border  extends  beyond  the 
navel  below.  Palpation  reveals  widely  advanced  carcinoma  of 
the  gall-bladder,  and  everywhere  in  the  liver  scattered  hard 
nodules.  Therefore,  immediate  closure  of  the  abdominal  wound 
by  through  and  through  silk  interrupted  and  some  skin  sutures. 

Course. — The  temperature  remains  in  normal  limits  (highest 
evening  temperature  in  rectum,  37.6°).  After  6  days,  even 
before  the  removal  of  the  sutures,  Mrs.  S.  was,  upon  the  request 
of  her  relatives,  removed  in  a  wagon  to  her  home.  There  she 
died  8  weeks  later  of  cancerous  cachexia. 

In  the  following  case  there  was  a  suspicion  of  cancer ;  although 
jaundice  did  not  occur,  a  radical  operation  was  shown  to  be 
impossible. 

Mrs.  A.  H.,  57  years,  widow,  from  Oslerwieck.  Entered,  21. 
II.  97.  Oper.,  23.  II.  97.  Cystostomy.  Discharged,  12.  12. 
97.     UnreHeved. 


CLINICAL  AND  OPERATION  HISTORIES.  2  2/ 

Amnesis. — Parents  dead  ;  of  brothers  and  sisters  all  are  liv- 
ing. Patient  married  in  i  '^()'J ,  is  the  mother  of  6  children  ;  i  of 
them  died  a  year  old.  Since  about  a  year  ago  the  patient  ex- 
periences pains  in  the  right  upper  abdominal  region,  which 
radiate  to  the  sacrum  ;  with  these  there  exists  distress  of  stom- 
ach, especially  after  eating.  The  troubles  constantly  increased. 
Upon  the  advice  of  Dr.  Wiegandt  the  patient  came  hither. 

Status  Prsesens.  —  Medium-sized,  moderately  corpulent 
woman.  Lungs,  heart  and  urine  normal.  In  the  right  upper 
abdominal  region  a  hard  tumor  to  be  felt ;  some  pain  on  pressure. 
No  jaundice.     Suspicion  of  cancer  of  the  gall-bladder. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision. 
Large  gall-bladder,  contains  lo  stones.  Walls  somewhat  thick- 
ened. Cancer  in  neck  of  the  gall-bladder,  likewise  in  the  liver  and 
glands.  Radical  extirpation  impossible.  Attachment  of  the 
gall-bladder  after  removal  of  the  stones.  Closure  of  the  lower 
part  of  the  wound.     Tube  drainage. 

Smooth  course  (highest  evening  temperature,  ^7-7'^^'  Dis- 
charged with  granulating  wound  and  biliary  fistula.  Report  by 
her  physician  at  the  end  of  February,  '98,  says  that  the  biliary 
fistula  has  closed,  and  that  the  patient  enjoys  a  relatively  good 
condition.      In  May  she  died  of  cancerous  cachexia. 

The  cystostomy  in  carcinoma  of  the  gall-bladder  achieves 
frequently  a  diminution  of  the  distress,  for  there  is  often  asso- 
ciated a  calculous  cholecyslitis.  If  one  then  drains  the  gall- 
bladder, the  pains  cease.  On  the  other  hand  there  arises,  if  the 
disease  extends  further,  soon  a  very  trying  mucous  fistula,  and 
the  value  of  such  palliative  operations  is  extremely  slight.  It 
would  be  best,  if  one  left  such  cases  in  peace,  contented  himself 
with  an  exploratory  operation,  and  only  then  operated  if  a  radi- 
cal cure  was  possible.  That  is  to  be  attained  only  by  an  early 
diagnosis,  and  unfortunately  at  first  cancer  of  the  gall-bladder 
produces  only  very  slight  disturbances  of  the  stomach  ;  if  it  is 
to  be  diagnosticated,  then  usually  a  radical  cure  is  no  longer  to 
be  attained. 


228  GALLSTONE  DISEASE. 

The  following  case  was  one  of  far  advanced  cancer  of  the  gall- 
bladder in  which  an  operation  was  refused  : 

Mrs.  P.  Sch.,  from  Timmenrode,  47  years.  Father  and  mother 
living  and  healthy  ;  of  4  brothers  and  sisters,  2  are  dead  and  2 
living  in  health.  Patient  married,  has  had  8  confinements,  one 
miscarriage  ;  after  the  birth  of  the  first  child  the  puerperium  was 
feverish,  there  was  vomiting,  constipation  and  discharge.  At- 
tacks of  pain  often  occurred  in  the  right  upper  part  of  the  abdo- 
men. All  troubles  have  increased  after  the  succeeding  lyings-in. 
In  March,  1896,  the  patient  is  said  to  have  had  rheumatism 
(articular  rheumatism),  she  was  for  a  time  confined  to  bed  ;  in 
the  autumn,  1896,  the  rheumatism  completely  disappeared.  Then 
a  disease  with  fever  and  bloody  expectoration  (not  vomiting) 
occurred  (perhaps  pneumonia).  At  the  end  of  1896  vomiting 
occurred,  the  appetite  became  bad,  emaciation  and  jaundice  oc- 
curred in  the  middle  of  September  ;  now  there  is  constipation, 
the  vomiting  subsides,  pains  in  the  right  side  of  the  abdomen  in 
paroxysms,  continued  emaciation.  In  September,  1897,  the  at- 
tending physician.  Dr.  Moll,  discovers  in  the  right  hypochon- 
drium  a  tumor  which  is  very  painful.  Since  persistent  pain  in 
the  stomach  exists,  and  the  jaundice  increases,  he  proposes  an 
operation.  P^ntered,  13.  10.  97.  It  was  determined  that  the 
tumor  was  the  gall-bladder,  it  was  stony  hard,  knobby,  and  also 
hard  nodules  were  to  be  felt  on  the  upper  surface  of  the  liver. 
Slight  ascites.  Intense  jaundice.  Spleen  not  enlarged.  Cachexia. 
Complete  loss  of  appetite.  Carcinoma  of  the  gall-bladder  with 
extension  to  the  cystic  and  common  ducts  certain.  Operation 
refused.  Discharged,  17.  10.  97.  Died  6  weeks  later  in  Tim- 
menrode of  cancerous  cachexia.    Autopsy  verified  the  diagnosis. 

Fever  and  pain  frequently  are  wanting  in  cancer  of  the  liver. 
In  the  following  case  \hQ.  fever  was  so  high  and  the  pains  so  pro- 
nounced, that  the  attending  physician  at  first  had  thought  of 
gallstones. 

W.  D.,  48  years,  writer,  from  Ilsenburg.  PLntered,  3.  6.  98. 
Operation,  5.  6.  98.    Exploratory  incision.    Cancer.    8.  6.  98,  died. 


CLINICAL  AND  OPERATION  HISTORIES.  229 

Amnesis. — Patient,  whose  parents  are  dead,  has  still  3  brothers 
and  sisters,  one  brother  died  as  a  child.  Patient  was  healthy 
except  for  occasional  pain  in  the  stomach  in  recent  years,  in  ad- 
dition a  great  deal  of  eructation.  First  on  March  23  of  this 
year  there  occurred  violent  girdle-pains  in  the  epigastrium,  which 
lasted  some  days.  Vomiting  did  not  occur.  The  patient  felt 
himself  for  some  3  weeks  undisturbed,  and  then  again  girdle- 
pains  at  the  level  of  the  navel,  no  vomiting.  Then  again  im- 
provement. For  three  weeks  continued  discomfort,  on  the  right 
violent  pains,  never  vomiting.  Patient  is  very  much  emaciated, 
and  comes  at  the  suggestion  of  Dr.  Stephan  of  Ilsenburg  hither. 

Status  Prsesens. — Medium-sized,  spare  man  of  tawny  color. 
Liver  enlarged,  gall-bladder  not  to  be  felt,  liver  sensitive,  no 
jaundice,  other  organs  normal.  On  the  3.  and  4.  6.  tempera- 
ture up  to  39°  C. 

Diagnosis. — An  exact  diagnosis  cannot  be  made.  On  account 
of  the  high  degree  of  distress  and  the  fever  one  at  first  thought 
of  a  severe  inflammatory  process  in  the  gall-bladder.  Explora- 
tory incision. 

Operation. — Chloroform  anaesthesia.  20  minutes.  Longi- 
tudinal incision  in  the  right  rectus  muscle  discloses  a  generally 
enlarged  liver,  upon  the  upper  surface  of  which  are  numerous 
white  prominences,  the  size  of  a  20-pfenning  piece.  Such  a 
tuberosity  is  excised  for  microscopic  examination  purposes. 
Suture  with  three  fine  sutures.  Gall-bladder  normal.  Closure 
of  the  abdominal  wound  with  interrupted  through  and  through 
and  some  skin  sutures. 

The  temperature  on  the  5.  6.  in  the  evening  reaches  ^8.6°, 
on  6.  6.  evening  39.3°.  Patient  sinks,  the  pulse  becomes  fre- 
quent, sensorium  obtunded  ;  temperature  7.  6.  evening  38.7°, 
in  the  night  of  the  8th  death  occurred.     Autopsy  not  allowed. 

It  is  a  great  disadvantage  of  private  clinics  that  one  can  sel- 
dom make  an  autopsy ;  the  bodies  are  removed  already  on  the 
day  of  death,  and  almost  always  a  necropsy  is  refused.  We 
must  in  almost  all  cases   content   ourselves  with   the    revision  of 


230  GALLSTONE  DISEASE. 

the  wound.  Whether  in  this  case  the  fever  depended  upon  the 
cancer,  or  whether  somewhere  else  there  were  inflammatory 
changes,  remains  undecided.  The  diagnosis  of  carcinoma  was 
verified  by  the  Pathological   Institute  in  Gottingen. 


9- 
Acute  Obstruction  of  the  Common  Duct  by  Stone. 

The  acute  obstruction  of  the  choledochus,  the  gallstone  colic 
za-'s|o;^r^v,  is  seldom  observed  by  a  surgeon,  and  still  seldomer 
by  them  operated  upon.  In  the  first  part  of  my  book  I 
have  given  the  reasons  why  one  best  declines  operation  in  acute 
obstruction  of  the  common  duct.  In  the  following  case  also  the 
patient  was  discharged  from  the  clinic  without  operation. 

Mrs.  L.  v.,  from  Langeln,  30  years,  mother  of  4  healthy  chil- 
dren. Patient  is  said  never  to  have  been  seriously  ill.  For  5  years 
has  suffered  from  cramps  in  the  stomach,  which  occur  at  differ- 
ent intervals.  With  them  much  vomiting,  never  jaundice. 
Bowels  costive.  During  the  last  year  the  cramps  in  the  stom- 
ach have  softened  into  a  constant  feeling  of  pressure  in  the  re- 
gion of  the  gall-bladder.  Suddenly  on  the  6.  6.  96  Mrs.  V. 
suffered  a  very  violent  typical  attack  of  colic,  associated  with 
intense  jaundice.  Constipation,  urine  was  dark-brown  colored. 
On  account  of  the  violent  pains  Mrs.  V.,  on  the  advice  of  Dr. 
Hermann  of  Wasserleben,  determined  to  enter  the  clinic  on 
6.  96. 

Status  Prsesens. — Medium-sized,  well-nourished  woman  ; 
marked  jaundice,  violent  itching.  In  the  region  of  the  gall- 
bladder marked  sensitiveness  to  pressure,  no  tumor.  The  lower 
border  of  the  liver  extends  three  finger-breadths  under  the 
curvature  of  the  ribs  ;  above  there  is  no  displacement  of  the 
boundaries.  Spleen  not  enlarged.  Urine  contains  biliary  coloring 
matter,  otherwise    nothing   abnormal.     The    stools,  which  fol- 


CLINICAL  AND  OPERATION  HISTORIES.  23  I 

lowed  castor  oil,  were  completely  white.  No  fever  ;  pulse  regu- 
lar, strong,  66  beats  in  the  minute. 

Diagnosis. — Acute  obstruction  of  the  common  duct. 

Since  one  ought  not  to  operate  in  cases  of  acute  obstruction 
of  the  common  duct,  the  patient  was  treated  only  symptomati- 
cally ;  hot  poultices  upon  the  abdomen,  castor  oil  for  the  con- 
stipation, morphine  for  the  pain.  The  stools  were  carefully 
examined,  but  no  stones  found  in  them.  The  white  color  dis- 
appeared ;  on  the  1 1 .  6.  normal  brown  stool,  with  4  pea-sized 
stones.  Patient  was  afterwards  free  from  distress,  and  preferred 
to  leave  the  clinic  on  the  13.  6.  **  In  case  her  pains  should  re- 
turn she  would  submit  to  operation."  We  had  no  reason  on  the 
expulsion  of  the  stones  to  urge  the  undertaking  of  an  operation. 
Since  then  the  patient  has  often  had  colics  without  the  passage 
of  stones,  so  that  the  operation  was  indicated,  but  the  patient 
had  such  a  fear  of  the  anaesthesia  that  she  had  rather  endure 
the  pains. 


10.  II. 
Chronic  Obstruction  of  the  Common  Duct  by  Stone. 

Stones  in  the  common  duct  may  be  just  as  quiet  as  in  the  gall- 
bladder^ a  fact  which  is  proven  to  a  certainty  by  the  following 
case  : 

Mrs.  S.,  58  years,  from  Halberstadt.  Entered,  30.  9.  96. 
Open,  14.  10.  96.  Cystostomy  of  the  gall-bladder  adherent  to 
the  abdominal  wall.  Choledochotomy  without  suture.  Dis- 
charged, 3. 11.96.  Incomplete  cure.  The  54  years  old  patient 
was  operated  upon  by  me  by  cystostomy  on  February  23,  1893. 
At  that  time  I  removed  a  bean-sized  solitary  stone.  End  of 
1 894 — also  I  y^  years  later — she  again  had  colic,  with  jaundice. 
It  was  shown  that  a  silk  suture  had  dropped  into  the  gall-blad- 
der and  had  led  to  incrustation,  for  a  stone  expelled  with  the 
stools  contained  as  a  nidus  a  knotted  silk  suture.      One  year 


232  GALLSTONE  DISEASE. 

later  the  patient  in  October,  1895,  again  had  trouble.  The  gall- 
bladder was  to  be  felt  as  a  tense,  very  painful  tumor,  cholangitic 
symptoms,  fever  and  chills  appeared.  Since  the  condition  was 
threatening  I  opened  in  the  old  laparotomy  scar  into  the  gall- 
bladder, which  was  adherent  to  the  abdominal  wall.  Evacuated 
considerable  offensive  bile  and  a  stone,  which  again  enclosed  in 
itself  as  nidus  a  silk  suture.  The  patient  gained  strength,  but 
the  escape  of  bile  was  so  profuse  that  I  assumed  the  presence  of 
other  stones  in  the  common  duct. 

For  this  reason  the  abdomen  was  opened  in  the  middle  line 
above  the  navel  and  the  suspected  stone  immediately  felt ;  dur- 
ing the  fixation  for  the  purpose  of  incision  it  went  to  pieces,  so 
that  I  also  had  involuntarily  done  a  choledochotripsy.  Since  no 
further  stones  were  to  be  felt  the  abdominal  cavity  was  closed. 
The  desired  closure  of  the  fistula  did  not  occur  ;  about  3  months 
long  bile  flowed  profusely  from  the  fistula,  so  that  I  was  obliged 
with  positiveness  to  assume  that  there  were  still  other  stones  in 
the  choledochus.  The  plugging  experiment  confirmed  this  as- 
sumption, but  the  woman  would  of  further  operations  have  none, 
for  which  one  cannot  blame  her.  Now  there  occurred  some- 
thing which  astonished  me — the  bihary  fistula  healed  ;  in  the 
meantime  the  patient  had  no  pains,  although  quite  certainly 
stones  must  yet  remain  in  the  choledochus.  In  the  stools,  which 
were  always  carefully  searched,  no  stone  was  ever  found  ;  no 
stone  could  have  passed  in  the  interval.  The  patient  recovered 
and  felt  herself  entirely  well,  had  excellent  appetite,  undisturbed 
action  of  the  bowels,  complete  absence  of  pain.  Once  in  October 
of  the  previous  year,  about  6  months  after  the  closing  of  the 
fistula,  was  she  tortured  quite  suddenly  with  a  fearful  attack  of 
colic  with  jaundice  and  high  fever,  and  after  8  days  in  bed 
severely  ill  was  brought  to  my  clinic.  The  entire  liver  was  sen- 
sitive, the  pulse  small  and  accelerated,  the  temperature  very  high, 
lips  and  tongue  dry — in  short  the  patient  gave  the  impression  of 
a  severe  septic  case.  I  opened  on  the  14th  of  October,  1896, 
the  tensely-filled  gall-bladder ;  found  in  it  considerable  muddy 


CLINICAL  AND  OPERATION  HISTORIES.  233 

bile,  but  no  stones,  and  pushed  forward,  since  a  revision  of  the 
common  duct  was  the  principal  aim,  through  an  incision  in  the 
median  line  above  the  navel  to  the  common  duct.  The  many 
operations  which  I  had  already  done  on  the  woman  had  at  least 
the  one  advantage  ;  I  was  operating  in  no  free  abdominal  cavity, 
but  in  adhesions,  and  in  fact  I  reached  the  choledochus  without 
opening  the  free  abdominal  cavity.  Very  quickly  I  found  a  large 
stone  in  the  common  duct,  which  I  did  not  crush  this  time,  but 
cut  out  of  the  duct.  I  now  could  wash  out  the  hepatic  and 
common  ducts,  since  I  had  no  fear  of  the  fluid  entering  the  free 
abdominal  cavity. 

Since  a  quantit)^  of  stone  fragments  came  to  view,  and  since 
despite  a  half-hour  washing,  mudd}^  bile  still  escaped,  I  drained 
the  common  duct  both  toward  the  liver  and  intestine  each  with  a 
rubber  tube.  The  abdominal  wound  was  not  closed,  but  tam- 
poned. The  procedure  had  a  wonderful  effect.  The  patient 
immediately  became  free  from  fever  and  recovered  in  a  few  days. 
The  drainage  worked  admirably,  so  that  never  a  drop  of  bile 
flowed  by  into  the  intestine.  After  6  days  I  removed  the  tube 
and  with  a  special  curved  metal  catheter  washed  out  daily  for 
weeks  the  hepaticus  and  choledochus,  through  which  for  a  long 
time  fragments  of  stones  and  muddy  bile  appeared.  It  was  espe- 
cially easy  through  the  papilla  to  enter  the  duodenum,  so  that  I 
could  spare  the  patient,  who  had  a  great  reluctance  to  taking 
castor  oil,  taking  it  by  the  mouth.  Since  I  daily  washed  out  and 
probed,  I  simply  injected  through  the  catheter  introduced  into 
the  duodenum  from  the  choledochus,  as  often  as  it  was  neces- 
sary, a  sufficient  quantity  of  castor  oil.  This  application  made  a 
decidedly  greater  impression  on  the  patient  than  all  the  choledo- 
cotomies  and  cystostomies  previously  done  by  me  upon  her,  and 
she  was  always  of  the  opinion  that  the  administration  of  oil  in 
this  manner  was  practicable  ;  that  it  let  her  forget  easier  the 
many  pains  which  she  had  endured  before  and  after  the  opera- 
tions ;  for  the  taking  of  castor  oil  is  worse  than  the  opening  of 
the  belly — a  wonderful  view  in  which  very  few  of  all  patients  will 


234 


GALLSTONE  DISEASE. 


coincide.  After  a  considerable  time  clear  bile  escaped,  no  more 
fragments  came  to  appearance,  I  permitted  the  gall-bladder  and 
choledochus  fistul?e  to  heal,  and  could  then  discharge  the  patient 
as  cured  on  the   3.  1 1. 

On  the  6.  1 1.  98  the  son  announces  that  his  mother  again  has 
severe  attacks  and  that  recently  stone  fragments  have  often 
passed  with  the  stools.  With  me  there  is  no  doubt  that  we  have 
to  do  not  with  a  new  formation  of  stones,  but  with  the  leaving  of 
stone  fragments  ;  from  this  case  it  is  evident  how  difficult  it  is  at 
once  to  remove  all  stones  from  the  choledochus.  A  type  of  the 
chronic  obstruction  of  the  choledochus  by  stone  is  the  following  case. 
The  gall-bladder  was  small,  contracted,  empty  of  stones;  in  the 
choledochus  there  was  one  large  stone.  Fever,  jaundice — every- 
thing was  very  characteristic  of  cJironic  obstruction  of  tlie  chole- 
dochus. 

A.  A.,  49  years,  wife  of  a  banker,  from  Cassel.  Entered, 
18.  6.  98.  Operation,  21.6.98.  Choledochotomy.  Discharged, 
4.  9.  98.     Cured. 

Amnesis. — Parents  dead,  3  sisters  are  living  and  healthy.  Pa- 
tient married  in  1885,  mother  of  i  child  (born  1889);  11  years 
ago  during  pregnancy  convulsions  which  ended  in  miscarriage. 
For  2  or  3  years  distress  in  stomach  which  rarely  occurred  :  pains 
in  the  stomach,  later  cramp-Hke.  At  the  end  of  January,  1898, 
after  an  error  in  diet  for  the  first  time  an  attack  of  cramp  in  the 
stomach  with  vomiting  ;  the  pain  lasted  some  hours,  afterwards 
a  journey  to  Berlin,  there  very  frequent  attacks  of  pain  without 
jaundice.  The  23d  of  February  first  real  colic  :  this  recurred 
frequently,  no  jaundice.  In  the  beginning  of  March  jaundice 
appeared,  the  intensity  of  which  varied  until  complete  discolora- 
tion of  the  skin.  The  colics  left  behind  them  in  the  intervals  a 
disagreeable  sensation  in  the  right  upper  region  of  the  abdomen. 
Much  morphine,  hot  poultices,  oil  internally.  At  the  end  of 
May  journey  to  Carlsbad  ;  after  the  immediate  beginning  of  the 
cure  other  kinds  of  pain  appeared,  intermittent  fever  and  jaundice, 
girdle  and  sacral   pains.      This  jaundice  remained  in    somewhat 


CLINICAL  AND  OPERATION  HISTORIES.  235 

varying  degree  without  entirely  disappearing  :  scarcely  further 
use  of  the  treatment,  stools  usually  without  color,  yet  sometimes 
completely  normal.  Loss  of  flesh  during  the  entire  time  about 
40  pounds,  in  Carlsbad  alone  8  pounds,  principally  through  the 
profuse  vomiting  during  the  colics.  Urine  often  examined, 
found  free  from  albumin  and  sugar.  Dr.  Spitzer,  of  Carlsbad, 
urges  operation  and  refers  the  patient  to  my  clinic. 

Status  Prsesens. — Medium-sized,  jaundiced  woman  with  con- 
siderable fat,  organs  without  anything  especial,  heart  somewhat 
enlarged,  sounds  pure,  urine  free  from  albumin  and  sugar,  con- 
tains bile  coloring  matters.  Region  of  the  gall-bladder  scarcely 
sensitive  to  pressure,  liver  not  enlarged,  no  tumor  to  be  palpated. 

Diagnosis. — Lithogenous  obstruction  of  the  choledochus. 

Operation. — Disturbed  chloroform  anaesthesia,  i  )^  hours. 
Large  longitudinal  incision  in  the  right  rectus,  liver  congested, 
hard,  jaundiced,  not  enlarged,  gall-bladder  adherent  to  the 
omentum  and  stomach,  contracted  to  the  size  of  a  pigeon's  Qgg, 
without  stones  ;  the  choledochus,  which  after  the  separation  of 
the  adhesions  which  are  particularly  developed  in  the  region  of 
the  cystic  duct,  is  very  accessible,  dilated  and  almost  as  large 
as  the  little  finger ;  a  large  stone,  quickly  felt  in  the  retroduo- 
denal  part,  is  by  the  bimanual  procedure  pressed  up.  Incision 
in  the  supraduodenal  portion  of  the  choledochus  and  extraction 
of  a  longish,  yellow,  granulated  cholestearin  stone  of  the  size  of 
a  cherry.  Clear  bile  immediately  escapes  from  the  opening, 
probing  does  not  detect  further  stones.  Closure  of  the  incision 
with  7  fine  silk  sutures,  tampon  down  to  the  suture,  abdominal 
walls  over  the  liver  closed  with  through  and  through  interrupted 
sutures,  up  to  the  opening  for  the  removal  of  the  gauze,  the 
lower  part  of  the  wound  by  the  means  of  muscular,  fascial  and 
peritoneal  sutures,  skin  sutures. 

The  course  was  so  far  good,  that  the  sutures  in  the  chole- 
dochus held  and  bile  never  escaped,  the  stools  were  brown,  the 
urine  free  from  the  bile  coloring  matters  and  the  jaundice  dis- 
appeared.     Elevation  of  temperature  occurred  only  very  transi- 


236  GALLSTONE  DISEASE. 

torily,  and  reached  no  more  than  38.0°.  On  the  other  hand, 
the  heahng  of  the  wound  did  not  entirely  go  as  desired.  The 
skin  stitches  suppurated,  and  after  their  removal  on  the  first 
change  of  dressings,  on  the  30.  2.  the  skin  wound  separated. 
The  wound  must  be  left  to  heal  by  granulations.  In  consequence 
frequent  change  of  dressings  must  be  made,  with  it  some  of  the 
deep  sutures  were  removed.  The  general  condition  of  the  patient 
was  always  excellent,  the  appetite  was  very  good.  Mrs.  A., 
indeed  to  her  disgust,  increased  in  weight.  On  4.  9.  the  patient 
was  discharged,  after  that  the  wound  had  contracted  down  to  a 
narrow  strip  of  granulations.  Her  son,  himself  a  surgeon,  dresses 
her  at  home.  The  jaundice  had  already  disappeared  in  two 
weeks  after  the  operation. 

The  patient  had  on  her  reception  only  jaundice,  the  fever 
attacks  which  had  occurred  so  often  in  Carlsbad  had  disappeared, 
she  felt  herself  so  well  that  she  would  not  hear  of  an  operation. 
In  such  a  case  one  must — if  the  palpation  data  are  negative — 
make  the  diagnosis  and  indication  for  operation  upon  the  ground 
of  the  amnesis.  I  had  no  doubt  that  there  was  chronic  litho- 
genous  obstruction  of  the  choledochus,  and  on  that  account  I 
could  only  advise  operation.  Here,  also,  by  reason  of  the  "  bi- 
mamial  procedure,''  the  incision  of  the  retroduodenal  portion  of 
the  choledochus  was  unnecessary-. 

According  to  recent  information  all  goes  very  well  with  the 
patient.  The  next  clinical  history  gives  again  just  as  typical  a 
case  of  chronic  obstruction  of  the  choledochus  by  a  stone. 

O.,  46  years,  laborer's  wife,  from  Thale  i.  Harz.  Entered,  21. 
I.  97.  Operation,  23.  i.  97.  Choledochotomy,  cystostomy. 
Discharged,  21.  2.  97.      Cured. 

Twenty-one  years  ago  already  pains  in  stomach,  ''ordinary" 
colics  5  years  ago.  For  a  year  frequently  jaundiced.  The  one 
physician  assumed  a  chronic  obstruction  of  the  choledochus  by 
a  stone,  the  other  repudiated  this  diagnosis,  since  he  had  always 
seen  the  woman  without  jaundice.  Despite  the  fact  that  she 
always  again   became  white,  the  itching  persisted.     The  pains 


CLINICAL  AND  OPERATION  HISTORIES.  237 

are  slight,  endurable,  yet  the  woman  is  not  able  to  manage  her 
household  or  to  care  for  her  6  children.  The  appetite  is  good, 
yet  she  gets  pains  in  the  stomach  always  after  heavy  foods. 

Examination. — No  jaundice,  moderate  enlargement  of  the 
liver,  no  tumor  of  the  gall-bladder.  In  the  urine  traces  of  bile 
pigment,  no  sugar,  no  albumin.  From  the  amnesis,  however, 
it  follows  that  we  have  to  do  with  an  intcrniiitcnt  cJ ironic  obstruc- 
tion of  the  cliolcdochiis  by  a  stone  ;  on  careful  inquiry  one  learns 
from  the  patient  that  she  has  frequently  chilly  sensations,  then 
she  becomes  very  yellow,  to  recover  her  normal  color  again  after 
a  couple  of  days.  She  is  obliged  often  to  loosen  her  jacket 
band,  since  she  has  pain  on  pressure. 

Diagnosis. — Stone  in  choledochus. 

Operation  on  the  23.  i.  97.  Medium-sized  gall-bladder.  In 
it  bile  and  3  small  stones.  Incision,  extraction.  On  the  cystic 
duct  an  adhesion  to  the  omentum.  Separation.  In  the  chole- 
dochus, which  is  the  size  of  the  thumb,  one  finds  immediately  a 
hazelnut-sized  stone,  which  is  quickly  removed  through  an  in- 
cision of  the  choledochus.  Four  sutures.  Cystostomy.  No 
tampon.  Duration  of  operation,  i  J^  hours.  Good  chloroform 
aUftsthesia.  The  course  was  completely  reactionless  ;  the  fistula 
excreted  in  the  first  week  a  considerable  quantity  of  bile,  then 
the  excretion  diminished.  On  the  19.  2.  the  fistula  is  closed. 
The  patient  was  discharged  on  the  21.  2.  without  pains.  Has 
remained  completely  well.  In  January,  1898,  she  was  delivered 
of  a  healthy  son.      She  has  never  again  had  any  sort  of  distress. 

The  next  clinical  history  represents  a  third  typical  case  of 
chronic  obstruction  of  tJie  cJiolcdocJius  by  stone.  The  amnesis 
comes  from  the  attending  physician,  and  already  from  this  can 
one  make  the  correct  diagnosis. 

Exc.  H.,  55  years,  lieutenant-general,  from  Dresden.  En- 
tered, 13.  10.  96.  Open,  15.  10.  96.  Ectomy.  Choledochot- 
omy.      Died,  18.  10.  96. 

The  history  comes  from  Dr.  Kelling,  of  Dresden,  to  whom  we 
owe  our  best  thanks   for  his  pains.      It  runs  :  The  patient  is  5  5 


238  GALLSTONE  DISEASE. 

years  old.  Father  died  at  90  of  old  age.  Mother  at  75  years 
(apoplexy).  Patient  himself  was  in  his  youth  healthy.  For- 
merly he  often  had  rheumatism.  At  45  years  once  an  attack  of 
violent  cramp-like  pains  in  the  region  of  the  liver,  which  the 
physician  declared  to  be  gallstone  colic.  Three  years  ago  the 
patient  was  in  Carlsbad  on  account  of  catarrh  of  the  stomach 
and  enlargement  of  the  liver.  Now  and  then  of  recent  years 
has  had  attacks  of  gout.  Present  suffering  began  in  September, 
1895,  after  drinking  cold  water.  The  patient  had  for  three  days 
after  a  diarrhoea.  Afterwards  the  patient  felt  weaker,  and  the 
appetite  was  less.  In  October,  1895,  jaundice  gradually  ap- 
peared. The  urine  was  dark,  the  bowels  constipated.  Nasty 
taste  in  mouth,  appetite  gone.  After  eating  sometimes  pain. 
Patient  lost  much  flesh.  In  the  course  of  the  year  there  oc- 
curred then  some  5-6  times  after  bodily  exertion  attacks  of 
chills,  followed  by  fever  up  to  39°  and  40°.  Sensitive  to  pres- 
sure in  the  region  of  the  liver,  increasing  jaundice.  The  jaun- 
dice then  again  receded  after  the  attacks,  yet  the  patient  is  said 
never  to  have  been  free  from  jaundice.  Some  2—3  times  the 
patient  has  had  attacks  of  severe  cramp-like  pains  in  the  region 
of  the  liver,  which  lasted  ^  day.  Patient  has  lost  in  all  some 
50  pounds.  The  stools  are  said  to  have  varied  in  color,  usually 
they  have  been  dark,  yet  sometimes  also  clay-colored.  For  2 
weeks  inclination  to  vomit.  Patient  has  daily  drunk  about  ^^ 
bottle  of  wine,  and  formerly  smoked  very  much.  On  the  27. 
8.  96  I  saw  the  patient  for  the  first  time.  Since  the  previous 
evening  he  had  had  violent  cramp-like  pains  in  the  region  of  the 
liver  and  great  sensitiveness  to  pressure  in  the  region  of  the 
gall-bladder.  Large  man  ;  layer  of  fat  had  disappeared,  skin 
and  conjunctivae  very  much  jaundiced.  No  oedema.  White 
coating  on  tongue.  Lungs  and  heart  normal.  Arterio-sclerosis 
of  radial  and  temporal  arteries.  Belly  sunken.  Spleen  even 
palpable.  Liver  enlarged,  somewhat  harder  than  normal.  In 
the  region  of  the  gall-bladder  clear  resistance,  which  is  sensitive 
to  pressure.     Temp.,  36.8°     Urine  dark  brown.      No  albumin, 


CLINICAL  AND  OPERATION  HISTORIES.  239 

no  sugar ;  considerable  bile  pigment.  Pupil  reflexes  good,  no 
tremor ;  patellar  reflexes  clear.  The  patient  has  now,  from  26th 
in  evening  to  28th  evening,  violently  raging  pains  and  dull  pres- 
sure in  the  region  of  the  gall-bladder.  With  this  clear,  sensi- 
tiveness to  pressure  in  this  region.  Repeated  injection  of  large 
doses  of  morphine  were  necessary.  On  the  28th,  11  o'clock 
P.M.,  the  cramp-like  pressure  ceased  with  a  jerk,  and  afterwards 
the  patient  did  well.  For  a  fortnight  the  stools  were  carefully 
searched  for  stones  without  success.  On  the  29.  8.,  jaundice 
markedly  more  pronounced  than  yesterday.  Urine  dark  brown  ; 
stool  by  enema.  First  part  of  the  stool  is  dark,  the  second 
lighter.  The  stools  then  become  darker  in  the  course  of  the 
next  day,  the  urine  lighter  and  the  jaundice  diminishes.  Appe- 
tite becomes  good.  On  the  9.  9.  the  jaundice  is  only  yet  very 
sHght.  On  the  30.  8.  examination  of  the  stomach-contents,  one 
hour  after  3  pfg.  worth  of  dry  semmel  and  2  glasses  of  water. 
The  semmel  is  well  digested  and  mixed  with  only  a  little  mucus. 
Reaction  to  free  hydrochloric  acid  strong.  Content  of  hydro- 
chloric acid,  o.  I  5  per  cent.  The  treatment  consists  in  fat  free 
diet,  drinking  of  buttermilk,  Carlsbad  Sprudel  as  well  as  Sprudel 
baths.  On  the  15.  9.  the  patient  71.50  kilogrammes.  On  20. 
9.  the  weight  amounted  to  73.200  kgs.  On  the  11.  9.  knifing 
and  sticking  pain  in  the  region  of  the  gall-bladder.  On  the  15. 
9.  in  the  morning,  a  40-minute  chill,  then  the  temperature 
mounted  to  38.8°  and  remained  as  high  24  hours.  The  liver 
is  diffusely  sensitive  to  pressure.  On  the  16.  9.  temperature 
normal.  Urine  darker,  skin  more  markedly  icteric,  stools  some- 
what lighter.  On  the  17.  9.  again  an  attack  of  pressure  and 
cutting  in  the  region  of  the  gall-bladder  of  6  hours'  duration. 
Afterwards  the  jaundice  is  very  intense.  Urine  entirely  beer- 
colored  and  stools  lighter.  Pronounced  loss  of  appetite.  The 
stool  becomes  gradually  darker,  the  urine  lighter  and  the  icterus 
diminishes  slowly. 

Status  on  the  7.   10.     Skin  greenish-yellow,  liver  diffusely  en- 
larged and  resistant,  more  marked  resistance  in  the  gall-bladder 


240  GALLSTONE  DISEASE. 

region.  Stools  light-brown.  Urine  light-brown  ;  little  appetite. 
On  the  9.  10.  the  stools  dark -brown,  urine  light,  jaundice  less. 

Diagnosis. — Chronic  obstruction  of  the  choledochus  from 
stone. 

Operation  on  the  15.  10.  96.  Morphine  -  atropine  -  ether 
anaesthesia.  Longitudinal  incision  in  the  right  rectus  muscle. 
On  opening  the  abdomen  there  appeared  the  enlarged  but  other- 
wise healthy-looking  liver.  First,  after  careful  separation  of  ex- 
traordinarily firm  adhesions  between  omentum,  stomach  and 
gall-bladder,  it  is  possible  to  free  the  latter.  It  is  small  and 
contracted  ;  in  it  no  stones  are  to  be  felt.  The  palpation  of  the 
choledochus  discloses  that  in  it  near  its  opening  into  the  intes- 
tine there  is  lodged  a  stone  about  the  size  of  a  plum.  Incision 
upon  the  same  retraction  and  separation  of  the  duodenum  toward 
the  left,  removal  of  the  stone  through  the  incision  wound,  after- 
wards closure  of  this  by  4  sutures.  The  remaining  large  bile 
ducts  were  free.  The  small  gall-bladder  is  opened  ;  it  contains 
no  bile,  no  stones.  Cystic  duct  obliterated,  therefore  extirpa- 
tion of  the  gall-bladder.  Partial  closure  of  the  abdominal  wound 
by  suture,  tamponade  of  the  abdomen  down  to  the  common 
duct.      Duration  of  the  operation,  three  hours. 

16.  10.  96.  Patient  feels  relatively  well.  Pulse  120,  strong, 
regular,  with  a  temperature  of  38.9°.  Belly  soft,  not  sensitive 
to  pressure.  No  vomiting.  17.  10.  96.  Twice  vomiting  of 
slimy  masses,  temperature  in  evening  38.6°,  pulse  120,  moderate 
strength.  No  symptoms  of  peritonitis.  Patient  complains  of 
difficult  breathing.  18.  10.  96.  Over  the  right  lung  behind 
and  below  bronchial  breathing  and  slight  dullness.  The  pulse 
is  small,  140  beats  in  the  minute,  temperature  39.4.  Camphor- 
ether  injections.  Exitus  in  the  evening  at  8  o'clock.  Autopsy 
results  of  the  abdomen,  no  peritonitis  ;  serous  covering  of  the 
intestines  glistening,  shining,  no  deposits.  No  exudation. 
Numerous  adhesions  so  that  the  field  of  operation  was  com- 
pletely shut  off  from  the  free  abdominal  cavity.  The  chest  was 
not  opened. 


CLINICAL  AND  OPERATION  HISTORIES.  24I 

As  a  rule  the  gall-bladder  in  chronic  obstruction  of  the  chole- 
dochus  by  stone  is  contracted  and  not  to  be  felt  as  a  tumor ^  as  in 
the  following  case  : 

W.,  43  years,  teacher,  from  Welsleben.  Entered,  6.  i.  97. 
Operation,  8.  i.  97.  Choledochotomy  and  cystostomy  (tube 
procedure).     Discharged,  io.  2.  97.      Cured. 

Patient  was  referred  to  the  clinic  by  Dr.  Stephan  of  Welsleben. 
He  is  said  to  come  from  a  healthy  family,  and  up  till  4  years 
ago  to  have  been  healthy.  About  this  time  pains  began  in  the 
pit  of  the  stomach  which  radiated  to  the  back.  No  vomiting, 
bowels  were  costive.  The  patient  suffered  especially  violent 
colics  lasting  several  hours  on  the  second  Easter  holiday  and 
Christmas.  Then  jaundice  also  occurred  ;  the  stools  during  the 
attack  were  grey,  the  urine  brown.  On  account  of  his  pains  the 
patient  visited  Carlsbad  in  the  middle  of  July.  A  four- weeks 
cure  made  there  brought  to  him  but  little  relief.  The  persistent 
pain  caused  him  finally  to  decide  upon  an  operation. 

Status  Praesens. — Large, emaciated  man ;  conjunctivae  slightly 
icteric.  Otherwise  no  jaundice.  Heart  and  lungs  normal.  In 
the  region  of  the  gall-bladder  sensitiveness  to  pressure,  but  no 
tumor  to  be  felt.  The  liver  reaches  2  finger-breadths  beyond 
the  curvature  of  the  ribs.  No  enlargement  of  the  spleen.  Urine 
is  of  brown  color,  contains  no  sugar  or  albumin  but  bile  pig- 
ment.     Stools  are  brown.      No  fever,  pulse  regular,  strong,  82. 

Diagnosis. — Probable  stone  in  the  ductus  choledochus ; 
adhesions. 

Operation  on  the  8.  i.  97.  Morphine-atropine-chloroform 
anaesthesia.  Longitudinal  incision  in  the  right  rectus  muscle. 
Opening  of  the  belly  ;  protection  of  it  by  inlaying  compresses. 
Only  after  the  careful  separation  of  numerous  firm  adhesions 
between  intestine,  omentum,  stomach  and  gall-bladder  could  the 
latter  be  made  accessible.  In  order  to  conveniently  reach  it  it  is 
necessary  to  make  at  the  level  of  the  navel  a  second  incision, 
perpendicular  to  the  first,  as  far  as  the  reflection  of  the  perito- 
neum.    Now  one  perceives  high  up  under  the  liver  the   slightly 


242  GALLSTONE  DISEASE. 

distended  contracted  gall-bladder.  On  puncture  some  lO  ccm. 
of  purulent  bile  is  removed.  The  gall-bladder  is  seized  by  liga- 
tures, and  by  a  3  cm.  long  incision  its  fundus  is  completely 
opened.  The  cystic  duct  is  very  much  thickened  ;  it  feels  stony 
hard,  but  is  free  from  stones.  At  the  opening  of  the  cystic  duct 
into  the  common  duct  one  clearly  feels  a  stone  about  the  size  of 
a  pigeon's  egg.  An  incision  is  made  upon  this,  and  after  the 
extraction  of  the  stone  is  closed  with  4  sutures.  The  probing  of 
the  choledochus,  which  was  done  immediately  before,  shows  that 
this  duct  both  toward  the  intestine  and  toward  the  hepatic  duct 
is  freely  passable  for  the  sound.  A  long  tube  was  introduced 
into  the  gall-bladder,  which  it  was  impossible  to  attach  to  the 
wound  because  of  its  position.  A  firm  tampon  was  introduced 
around  the  gall-bladder  and  the  choledochus  ;  the  abdominal 
wound  itself  was  in  great  part  closed  with  sutures.  Dressing. 
Duration  of  operation,  2  hours. 

Course. — On  the  morning  after  the  operation  temperature 
39.4°,  pulse  very  accelerated,  small.  Violent  vomiting  of  red- 
dish-brown masses.  The  belly  is  soft,  not  distended.  Bile  does 
not  escape.  Patient  very  restless.  Urine  on  the  first  day  600 
ccm.,  very  concentrated,  contains  considerable  bile  pigment. 
Administration  of  stimulants.  This  condition  lasted  4  days ; 
highest  evening  temperature,  39.3°;  highest  morning  tempera- 
ture, 38.7°;  pulse  varies  between  125  and  144.  Suddenly  on 
the  fifth  day  the  flask  is  half  filled  with  bile.  The  restlessness, 
from  which  the  patient  has  severely  suffered  very  much,  disap- 
peared. The  evening  temperature  amounted  to  38.2°;  in  the 
morning  the  patient  was  completely  free  from  fever  ;  no  vomit- 
ing. Spontaneous  expulsion  of  flatus.  On  the  first  change  of 
dressings  on  the  19.  i.  there  is  a  granulating  wound  cavity. 
The  suture  of  the  ductus  choledochus  has  held  well  ;  in  the 
opening  into  the  gall  bladder  a  new  tube  was  introduced  and  a 
tampon  about  it.  The  patient  now  improved  visibly ;  on  the 
29.  I .  he  left  his  bed  for  the  first  time.  The  wound  diminished 
more  and  more.     The   gall-bladder  fistula  had  closed    by  the 


CLINICAL  AND  OPERATION  HISTORIES.  243 

31.  I.  On  the  10.  2.  97  W.  was  discharged  from  the  cHnic  with 
a  granulating  streak-hke  wound.  The  report  of  the  very  thank- 
ful patient  on  the  17.  2.  98  gives  as  the  latest  news  that  he 
enjoys  the  best  of  health. 

Usually  a  colic  ushers  in  a  lithogcnous  obstruction  of  the  chole- 
dochus  ;  that  the  paijts  in  such  a  case  may  be  completely  wanting, 
and  that  jaundice  occurs  TvitJiout  the  slightest  indication  of  colic 
is  shown  by  the  following  case  : 

Mrs.  V.  D.,  38  years,  wife  of  a  chief  staff  surgeon,  from  Oppeln. 
Entered,  14.  11.  98.  Operation,  19.  11.  98.  Cystectomy, 
choledochotomy,  hepatopexy.      Discharged,  20.  12.  98.     Cured. 

Parents  of  the  patient  dead  (father  died  of  articular  rheuma- 
tism, mother  from  scurvy)  ;  a  younger  sister  of  the  patient  suffers 
with  her  stomach.  Mrs.  v.  D.  is  said  to  have  always  been 
healthy,  until  some  3  years  ago  she  suddenly,  after  a  dinner,  was 
taken  with  cramps  in  the  stomach  ;  the  attack  dragged  along  for 
days  and  was  attended  by  vomiting,  but  not  by  jaundice.  Then 
again  her  health  returned,  until  some  months  later  violent  vomit- 
ing with  cramp-like  pains  in  the  upper  abdominal  region  occurred 
in  such  a  manner  that  the  vomiting  brought  about  a  cessation  of 
the  pains.  A  half-year  again  the  good  health  lasted,  then  again 
violent  cramps  of  the  stomach.  Some  months  later  again  pains 
in  the  stomach.  Eight  months  later  there  suddenly  appeared 
jaundice,  accompanied  by  loss  of  appetite,  weakness  and  emacia- 
tion. The  appearance  of  jaundice  followed  in  February  of  this 
year  without  pain.  The  intensity  of  the  jaundice  varied.  A 
Carlsbad  cure  first  at  home  and  then  in  Carlsbad  remained  un- 
successful. The  color  of  the  stools  varied.  The  urine  was  dark, 
and  in  Carlsbad  only  for  a  short  time  lighter.  Until  now  the 
condition  remained  the  same.  The  emaciation,  which  until  then 
had  made  slow  progress,  in  the  last  fortnight  had  become  more 
pronounced.      In  all,  Mrs.  v.  D.  has  lost  22  pounds. 

Status  Prsesens. — Earge,  well-built  woman  of  moderate  con- 
dition of  nutrition.  Moderate  yellow  coloring  of  the  skin,  and 
visible   mucous   membranes.      Condition  of  the   organs  normal, 


244  GALLSTONE  DISEASE. 

save  an  enlargement  of  the  liver,  of  which  the  right  lobe  does 
not  terminate  at  the  curvature  of  the  ribs,  but  is  uniformly  en- 
larged ;  in  the  region  of  the  gall-bladder  slight  sensitiveness  to 
pressure.  In  the  urine  bile  pigment,  but  no  albumin  or  sugar. 
No  fever.  Stools  were  during  the  days  preceding  the  operation 
now  brown,  now  grey.  Exactly  by  reason  of  this  circumstance 
have  we  made  the  diagnosis  of  chronic  obstruction  of  the  chole- 
dochus  by  a  stone ;  a  new  growth  was  decidedly  improbable, 
despite  real  colics  .were  wanting. 

Operation,  lo.  ii.  98.  Longitudinal  incision  in  the  right 
rectus  abdominal  muscle.  Gall-bladder  size  of  a  hen's  egg,  and 
adherent  to  the  omentum.  Separation.  The  gall-bladder  is 
stony  hard.  In  the  supraduodenal  part  of  the  choledochus  an 
angular  stone.  Choledochotomy.  There  escapes  considerable 
muddy  bile.  Severe  hemorrhage  out  of  the  plexus  of  veins 
lying  upon  the  choledochus.  Extraction  of  the  stone.  Ex- 
cision of  the  gall-bladder  with  stones.  Walls  of  the  gall-blad- 
der very  much  thickened.  Overcasting  of  the  stump  of  the 
cystic  duct.  The  incision  of  the  choledochus  closed  with  3 
sutures  of  formaline  catgut.  Tamponade  to  the  cystic  duct 
stump  and  to  the  choledochus.  Suture  of  the  lower  border  of 
the  liver  to  the  parietal  peritoneum.  Closure  of  the  abdominal 
wound  with  through  and  through  thick  silk  sutures.  Gauze 
brought  out  of  the  upper  angle  of  the  wound.  Duration  of  the 
operation,  ^  of  an  hour.  Good  chloroform  anaesthesia.  The 
gall-bladder  shows  at  the  fundus  a  two-mark  sized  ulceration. 
The  Pathological  Institute  in  Gottingen  had  the  kindness  to  ex- 
amine the  gall-bladder,  and  reported  as  follows  regarding  its 
condition  : 

The  microscopical  examination  of  the  border  of  the  large 
ulcer  shows  in  the  sections  heretofore  made  only  the  pictures  of 
a  simple  ulcer,  there  is  nothing  of  a  malignant  epithelial  growth 
on  the  other  hand. 

The  course  was  afebrile.  On  the  first  day  some  vomiting. 
After  72  hours  one  found  bile  in  the  dressings.      It  was  wrapped 


CLINICAL  AND  OPERATION  HISTORIES.  245 

up.  On  the  succeeding  day  dressings  dry.  Pulse  alwa}'s  slow, 
temperature  never  above  37.6°  in  rectum.  On  the  30.  11. 
change  of  dressings.  No  bile  in  the  dressing.  Wound  looks 
fine.  Removal  of  stitches  and  the  gauze  tampon.  Stools  brown. 
Appetite  good,  sleep  fair.      Discharged,  20.  12.  98. 

Comments. — In  an  exceptional  manner  the  jaundice  appeared 
in  this  case  without  pain  ;  real  colics  were  wanting.  The  varia- 
tion of  the  jaundice  and  the  color  of  the  stools  permitted  in  this 
case  the  making  of  the  diagnosis  of  stone  in  the  choledochus. 
The  completely  packed  gall-bladder  had  probably  caused  abso- 
lutely no  distress.  The  ectomy  was  in  this  case  easier  than  the 
cystostomy,  and  more  correct,  because  of  the  deep  ulceration  of 
the  mucous  membrane.  The  escape  of  bile  from  the  chole- 
dochus, thanks  to  the  tampon,  gave  no  cause  for  anxiety  ;  the 
tampon  is  under  all  circumstances  necessary.  If  one  neglects  it 
md  completely  closes  the  abdominal  wound,  then  he  ought  not 
to  be  surprised  if  the  patients  die  of  peritonitis.  Riedel  does  not 
>eem  to  tampon  ;  he  ascribes  his  failures  to  the  infected  bile.  I 
Dclieve  rather  that  these  are  occasioned  by  his  not  having  tam- 
poned. Healthy  bile  is  sterile  ;  but  when  for  months  a  stone 
lies  in  the  choledochus,  then  the  bile  will  no  longer  be  com- 
pletely sterile.  If  it  can  escape  by  the  tampon,  then  it  will  not 
injure,  but  if  it  pours  out  into  the  abdominal  cavity,  then  peri- 
:onitis  will  not  fail.  I  have  so  frequently  observed  a  giving  away 
d(  the  choledochus  suture,  that  its  occurrence  no  longer  strikes 
ne  with  terror  ;  without  abundant  drainage  I  would  by  no  means 
iver  attempt  a  choledochotomy.  A  case  of  chronic  obstruc- 
:ion  of  the  choledochus  from  stone,  from  which  the  physician 
:an  learn  a  great  deal  in  i^elation  to  the  amncsis,  diagnosis  and 
'ndication  for  operation,  is  the  following  : 

Mr.  F.  H.,  50  years,  wine  dealer,  from  Bingerbriick.  En- 
ered,  20.  9.  98.  Oper.,  22.  9.  98.  Drainage  of  the  hepaticus. 
Z^losure  of  a  gall-bladder  and  stomach  fistula,  later  gastro-enter- 
xstomy.      Died  of  chola^mic  hemorrhage,  30.  9.  98. 

Amnesis. — Patient  had  as  a  child  a  running  ear  ;  in  the  loth 


246  GAT.LSTONE  DISEASE. 

year,  articular  rheumatism;  in  the  i8th  year,  a  disturbance  of 
the  stomach  lasting  5-6  months,  during  which  cramps  of  the 
stomach  occurred.  In  1883,  during  perfect  health,  he  suddenly 
was  attacked  with  violent  cramp-like  pains  in  the  region  of  the 
liver ;  the  pains  radiated  towards  the  back  and  the  shoulder 
blades,  lasted  several  hours,  and  first  let  up  after  morphine. 
With  this  no  vomiting,  no  fever,  no  jaundice.  These  attacks 
recurred  now  in  longer  (up  to  i  ^  years)  and  shorter  (to  8  days) 
intervals  until  the  end  of  1888.  With  these  the  bowels  were  con- 
stipated and  the  stools  more  or  less  devoid  of  color.  At  the 
end  of  1888  extremely  painful  attacks,  accompanied  by  fever, 
chills,  slight  jaundice,  white  stools,  beer-brown  urine.  Directly 
succeeding  such  an  attack  there  followed,  in  January,  1889,  the 
passage  of  a  large  gallstone.  Quickly  thereafter  good  health 
returned,  the  patient  recovered  his  strength,  was  completely  free 
from  distress,  and  also  remained  so  until  the  year  1891.  Then 
he  had  to  pass  through  a  very  suddenly-beginning  attack  con- 
sisting in  cramp-like  pains  in  the  region  of  the  gall-bladder  un- 
attended by  icterus.  Subsequently  there  constantly  occurred 
attacks  at  short  inten^als  ;  now  and  then  there  were  slight  eleva- 
tions of  temperature,  which  lasted  several  weeks  ;  the  skin  then 
became  yellow,  the  stools — always  constipated — greyish-white, 
the  urine  brown  with  yellow  foam.  In  the  intervals  between 
attacks  the  patient  was  weak,  dizzy,  disinclined  to  any  labor, 
he  suffered  from  loss  of  appetite,  pain  in  stomach  and  eructa- 
tions. From  1 892-1 897  the  patient  visited  Carlsbad  each  year, 
during  the  first  3  years  with  good  results  of  such  character  that 
during  the  stay  there  an  attack  only  seldom  occurred,  and  the 
remaining  distress  almost  completely  disappeared  ;  in  the  follow- 
ing years  in  Carlsbad,  however,  the  general  distress  (discomfort, 
loss  of  appetite,  slight  fever,  etc.)  did  not  yield.  Although  since 
the  year  1 896  no  other  real  attack  of  colic  occurred,  yet,  how- 
ever, the  patient  never  feels  well  ;  he  constantly  since  then  com- 
plains of  pain  in  the  stomach,  loss  of  appetite,  eructations,  flatu- 
lence  and  constipation.      In    October,    1898,    there  appeared  a 


CLINICAL  AND  OPERATION  HISTORIES.  2\J 

slowly-increasing,  persistent  icterus,  which  caused  violent  itching 
of  the  skin  (scratching  till  bleeding)  ;  since  then  slight  evening 
rise  of  temperature,  almost  colorless  stools,  persistent  beer-brown 
urine  ;  in  addition,  loss  of  weight  and  bad  general  condition. 
Through  a  cure  pursued  in  the  spring  of  this  year  at  Neuenahr, 
the  icterus,  the  itching  and  the  remaining  distress  diminished, 
but  after  the  completion  of  the  cure  recurred  with  the  same  in- 
tensity as  before.  Except  for  that  large  stone  no  other  stones 
have  been  passed. 

Status  Praesens. — Large,  spare  man.  Liver  large,  lower 
border  reaches  to  the  level  of  the  navel.  The  left  lobe  also  is 
considerably  enlarged.  Surface  smooth.  In  the  region  of  the 
gall-bladder  slight  painfulness,  more  still  tov/ard  the  median 
line.  Moderate  icterus,  in  urine  traces  of  albumin,  quantities  of 
bile-pigment,  no  sugar.  Spleen  and  gall-bladder  not  to  be 
lelt. 

The  diagnosis  is  made  of  chronic  lithogenous  choledochus 
obstruction,  carcinoma  indeed  to  be  excluded.  Gall-bladder 
probably  contracted  and  probably  empty  of  stones.  Very  char- 
acteristic are  the  variations  of  temperature,  which  greatly  weaken 
the  patient.  With  great  suddenness  the  temperature  rose  to 
39.0°  C,  the  icterus  increased,  the  itching  of  the  skin  became 
more  severe.  Already  from  these  symptoms  one  may  make  the 
diagnosis  of  chronic  obstruction  of  the  choledochus  by  stone. 
The  jaundice  was  completely  wanting  in  the  afebrile  periods. 
Not  by  reason  of  the  results  of  palpation  is  the  diagnosis  as- 
sured, but  solely  from  the  amnesis  and  the  previous  course  of 
the  disease. 

During  the  operation  one  had  to  be  prepared  for  many  adhe- 
sions, which  originated  in  the  perforation  of  the  large  stone  from 
the  gall-bladder  (?)  into  the  intestine  (still  existing  gall-bladder- 
intestinal  fistula).  The  attending  physicians  were  of  opposing 
opinions  regarding  operation.  The  one  was  for,  the  other 
against,  operation. 

Operation,  22.  9.   98.      Chloroform  anaesthesia.      254^  hours. 


248  GALLSTONE  DLSEASE. 

Longitudinal  incision  in  the  right  rectus  abdominal  muscle. 
Liv^er  enlarged.  Some  adhesions  between  omentum  and  abdom- 
inal wall.  Separation.  Gall-bladder  small,  adherent  to  the 
duodenum  (gall-bladder-duodenal  fistula).  Gall-bladder  appar- 
ently empty.  High  up  in  the  choledochus  one  feels  a  cylindri- 
cal body.  It  is  sought  to  free  the  stomach  from  the  choledo- 
chus, that  which  proved  itself  impossible.  The  route  from  the 
gall-bladder  to  the  deep-lying  parts  can  only  be  found  after  the 
previous  removal  of  the  gall-bladder-duodenal  fistula.  On  this 
account  separation  of  the  gall-bladder  from  the  duodenum. 
Repair  of  the  hole  in  the  duodenum  due  to  this  by  10  sero- 
serous  sutures.  Gall-bladder  contains  muddy  bile.  Cystic  duct 
patent.  Plugging  with  sterile  gauze.  Choledochotomy  after 
the  duct  is  very  much  elevated  by  a  finger  in  the  foramen  of 
Winslow.  Long  incision.  Removal  of  a  4  cm.  long  walnut- 
thick  stone  and  a  second  of  pea  size.  There  escapes  muddy 
bile  mixed  with  fragments  ;  it  smells  very  nastily.  On  this  ac- 
count drainage  of  the  hepaticus.  A  soft  tube  is  introduced 
6  cm.  towards  the  liver  into  the  choledochus.  Tube  in  the  gall- 
bladder (cystostomy  ;  tube  procedure).  Extensive  tamponade 
about  the  tubes  with  sterile  gauze  strips.  The  lower  laparotomy 
wound  is  closed  with  through  and  through  thick  silk  sutures. 
Good  anaesthesia  Pulse  100  after  the  operation.  Patient  seems 
somewhat  shocked.  The  diagnosis  was  confirmed  in  every 
respect  by  the  operation.  Solely  the  stone  in  the  choledochus 
had  caused  the  variations  of  temperature  ;  the  gall-bladder  was 
empty.  The  fistula  existing  between  the  gall-bladder  and  the 
duodenum  had  contributed  to  this  that  the  jaundice  was  only 
moderate,  but  it  occurred  just  as  soon  as  inflammation  occurred. 
The  bile  was  muddy,  and  on  this  account  I  refrained  from 
suturing  the  choledochus,  and  carried  out  drainage  of  the  hepa- 
tic duct. 

23.  9.  98.  Temperature  17.6^ .  Pulse  strong,  regular,  90. 
Midday,  12  o'clock  :  patient  had  the  first  24  hours  after  opera- 
tion  nothing  to   drink,  in  the  last  4  hours   e\'ery  i  5   minutes    i 


CLINICAL  AND  OrERATION  HISTORIES. 


249 


teaspoonful  of  meal  soup  or  milk  and  cognac.      In  all  880  ccm. 
of  bile  have  passed  in  the  last  24  hours. 

Evening.  Feeling  of  fullness  in  the  region  of  the  stomach, 
pressure  there.  Beginning  singultus.  Outwashing  of  the 
stomach,  removal  of  about  i  liter  of  blackish,  bilious  fluid. 

24.  9.  98.  Quantity  of  bile,  730  ccm.  No  fever.  Pulse 
strong,  regular,  90.  Belly  soft,  not  sensitive  to  pressure.  Until 
now  no  flatus.  Still  great  weakness,  no  distress  of  stomach. 
Evening  enema  of  water. 

25.  9.  98.  No  fever.  Pulse  96,  regular.  Good  general  con- 
dition. Feeling  of  tension  and  fullness  in  the  stomach  ;  abdomen 
nowhere  sensitive  to  pressure,  slightly  distended.  Thus  far  no 
passage  of  flatus.  In  the  course  of  the  day  several  glycerine 
enemata  and  irrigations  of  water.  With  two  glasses  of  bitter 
water  no  stool  resulted.  Quantity  of  bile,  430  ccm.  Evening 
small  quantity  of  thin,  gruel-like  feces.  From  time  to  time 
eructations. 

26.  9.  98.  Quantity  of  bile,  580  ccm.  Still  singultus.  No 
fever.  Pulse  100.  Belly  soft,  nowhere  sensitive  to  pressure. 
Castor  oil.  Large  grey  stool  without  flatus  (irrigation).  In 
afternoon  distress  much  singultus,  nausea,  great  weakness,  pulse 
120.  Heat  alternating  with  shivers.  Examination  discloses  an 
acute,  very  important  dilatation  of  the  stomach,  no  symptoms 
of  peritonitis.  Tubes  lie  in  position  and  act  well.  Outwashing 
of  stomach,  removal  of  great  quantities  of  blackish-brown  fluid. 
Morphine,  0.0 1. 

After  the  outwashing  the  general  condition  improved,  the 
previously  small  pulse  became  again  stronger,  and  the  singultus 
and  nausea  disappeared. 

27.  9.  98.  Stomach  again  large.  No  fever.  Pulse  120, 
small.  Weakness  and  stupor.  Change  of  dressings.  Tubes  re- 
moved. Wound  cavity  looks  well.  Tamponade  of  cavity  with 
sterile  gauze.  Outwashing  of  the  stomach.  Infusion  of  salt 
solution.      Nutrient  enemata.      Little  fluid  by  mouth.     27.  9.  98. 

Pulse    small,    120.      Great    weakness.     Belly    soft. 


250 


GALLSTONE  DISEASE. 


From  time  to  time  eructations.  Stomach  extends  two  finger- 
breadths  below  the  navel.  Outwashing  of  the  stomach,  hypo- 
dermoclysis.  Thereafter  improvement  of  the  general  condition 
and  pulse. 

By  the  mouth  some  wine,  bouillon  with  egg.  Nutritive  ene- 
mata. 

28.  9.  98.  Stomach  extends  again  a  hand's-breadth  below  the 
navel.  Much  eructation.  Very  great  w^eakness.  Pulse  small, 
120.  Belly  soft,  not  sensitive  to  pressure.  During  the  night 
voluntary  small,  brownish-black,  gruel-like  stool,  with  flatus. 
On  account  of  the  considerable  dilatation  of  the  stomach,  w^hich 
does  not  yield  in  spite  of  the  outwashings,  and  of  the  danger 
that  by  its  further  continuance  the  weakness  will  increase,  a  gas- 
troenterostomy w^as  decided  upon,  and  after  previous  outwash- 
ings of  the  stomach  and  infusion  of  salt  solution  was  executed 
under  Schleich's  anaesthesia  (gastroenterostomy  antecolica  anter.). 
No  pains.  Duration,  i  ^  hours.  Closure  of  the  abdominal 
wound  by  through  and  through  interrupted  sutures.  The 
wound  down  to  the  choledochus  looks  well. 

29.  9.  98.  Patient  seems  shocked.  Pulse  small,  140.  Belly 
everywhere  soft,  nowhere  sensitive.  Flatus  passes  voluntarily. 
Camphor-ether  injection.  Hypodermoclysis.  Administration 
of  strong  black  coffee,  etc.,  causes  only  transitory  improvement. 
On  change  of  dressings  the  tampon  of  the  choledochus  wound 
is  soaked  with  dark  brown  blood  ;  hemorrhage  from  the  walls 
of  the  wound  cavity,  severer  hemorrhage  from  the  choledochus 
wound.  The  case  is  surely  one  of  cholaemic  hemorrhage.  Tam- 
ponade of  the  wounds  ;  stimulants.  On  the  30.  9.,  afternoon, 
at  half-past  one  o'clock,  death  ensued.  Necropsy  impossible, 
since  a  few  hours  after  the  body  w^as  taken  to  Bingerbriick.  • 

The  patient  had  borne  relatively  well  the  choledochotomy 
and  drainage  of  the  hepatic  duct ;  there  was  never  any  fever. 
The  acute  dilatation  of  the  stomach,  to  which  Riedel  first  called 
attention,  was  at  times  observed.  The  outwashings  of  the 
stomach   used  to  counteract  it  and  the  subsequent  morphine  in- 


CLINICAL  AND  OPERATION  HISTORIES.  25  I 

jections  were  of  only  temporary  benefit.  The  i^astroenteros- 
tomy  undertaken  on  this  account  was,  under  Sleich's  anaesthesia, 
easily  done  and  the  dilatation  was  overcome.  In  spite  of  this, 
the  severest  complication,  cholaemic  hemorrhage,  occurred. 

The  case  is  for  those  who  always  recommend  delay  in  chronic 
obstruction  of  the  choledochus  an  admonition  to  alter  their 
views.  Chronic  obstruction  of  the  choledochus  makes  the  pa- 
tients less  resistant,  and  alters  the  circulation  so  that  severe, 
even  uncontrollable,  hemorrhages  may  occur.  Had  the  patient 
come  earlier  (2  or  3  years  before),  then,  of  course,  he  might  at 
that  time  have  had  such  a  hemorrhage  ;  but  the  earlier  the  pa- 
tient comes  the  better  the  prognosis. 

One  ought  not  in  well  established  lithogenous  obstruction  of 
the  common  duct  delay  operation  longer  than  3  months  ;  then 
the  results  of  choledochotomy  will  be  good,  even  though,  of 
course,  they  will  never  reach  those  of  cystostomy.  We  will  not 
always  be  able  to  prevent  the  stone  entering  the  choledochus, 
but  we  may  and  must  take  care  that  it  does  not  so  long  tarry  in 
this  duct,  so  important  for  the  functions  of  the  liver,  otherwise 
there  arises  cholaemia,  cirrhosis  of  the  liver,  purulent  cholangitis, 
etc.,  and  then  all  the  endeavors  of  the  internal  physician  and  the 
surgeon  to  save  life  remain  without  success. 

A  combination  of  dropsy  of  the  gall-bladder  and  chronic  obstnw- 
tion  of  the  common  duct  belongs  to  the  rarities.  One  is  earnestly 
inclined  in  such  cases  to  assume  an  obstruction  of  the  choledo- 
chus by  tumor,  since  in  chronic  obstruction  of  the  choledochus 
by  stone  the  gall-bladder  is  not  usually  to  be  felt. 

Mrs.  CI.,  40  years,  building  inspector's  wife,  from  St.  Johann, 
near  Saarbriicken.  Entered,  4.  12.  98.  Operation,  6.  12.  98. 
Choledochotomy,  cysticotomy,  cystectomy,  hepatopexy.  Dis- 
charged, 31.  12.  98.      Cured. 

Amnesis. — Parents  are  living  and  healthy  ;  Mrs.  C.  as  a  girl 
was  anemic,  married  at  26  years,  is  the  mother  of  three  healthy 
children.  Constipation  has  existed  for  about  6  years.  The  appe- 
tite is  good,  yet  the  feeling  of  satiation  is  wanting,  and  already  for 


252 


GALLSTONE  DISEASE. 


years  there  have  been  pains  in  the  stomach,  especially  after  eating. 
The  first  cramp  in  the  stomach  occurred  1 3  years  ago  ;  the  attacks 
recurred  in  the  beginning  at  longer,  and  later  in  short  intervals. 
The  cramps,  which  formerly  lasted  half  an  hour  and  were  very 
violent,  from  time  to  time  attended  by  vomiting,  altered  their 
character  about  a  year  ago,  and  indeed  lasted  up  to  24  hours, 
but  their  intensity  was  less.  Five  weeks  ago,  after  a  moderate 
attack  of  pain,  a  slight  degree  of  jaundice  appeared  ;  after  that, 
this  was  almost  entirely  bleached  out ;  it  again  recurred  8  days 
ago  in  renewed  strength  after  slight  pains.  The  stools  v^aried 
decidedly  in  color,  after  the  attacks  they  were  light.  The  pas- 
sage of  stones  in  the  feces  was  not  observed.  Emaciation  is 
marked,  has  existed  since  a  severe  hemorrhage  6  years  ago  in 
consequence  of  a  confinement. 

Status  Prsesens. — Large,  spare  woman,  with  normal  organs. 
Enteroptosis.  In  the  region  of  the  gall-bladder  a  walnut- 
sized  sensitive  tumor  (gall-bladder),  the  liver  somewhat  en- 
larged.    In  the  urine  bile  pigment,  no  albumin  or  sugar. 

Diagnosis. — Stones  in  the  gall-bladder  and  cystic  duct. 
Dropsy  of  gall-bladder.  Adhesions.  Lithogenous  obstruction 
of  the  choledochus. 

Operation. — Longitudinal  incision  in  the  right  rectus  abdom- 
inal muscle.  Fundus  of  the  gall-bladder  enveloped  in  omental 
adhesions.  Separation.  In  the  cystic  duct  a  walnut-sized  stone. 
Cystostomy  and  then  cysticotomy.  In  the  gall-bladder,  clear 
mucus.  An  attempt  was  made  to  remove  the  stone  in  the 
choledochus  through  the  incision  in  the  cystic  duct ;  it  failed, 
hence  choledochotomy.  The  cystic  and  choledochus  (supra- 
duodenal part)  incisions  were  made  one  by  cutting  the  interven- 
ing tissue.  Extraction  of  2  stones.  Hepatic  and  common  ducts 
were  permeable  to  the  sound.  Suture  with  catgut.  Excision 
of  the  gall-bladder.  In  doing  this  one  sees  how  easy  it  is  by 
dragging  on  the  gall-bladder,  which  is  freed  from  the  under  surface 
of  the  liver,  to  put  the  ligature  about  the  cystic  duct,  also  over 
the  choledochus,  that  a  part  of  the  latter  may  be  comprised  in 


CLINICAL  AND  OPERATION  HISTORIES.  253 

the  ligature  and  thus  a  stenosis  arise.  It  is  on  this  account  to 
be  preferred  to  clamp  the  cystic  duct  toward  the  liver  by  put- 
ting a  broad  forceps  about  the  neck  of  the  gall-bladder,  in  order 
that  none  of  the  contents  of  the  gall-bladder  should  escape  into 
the  abdomen,  and  then  cut  across  the  cystic  duct,  so  that  one 
sees  its  lumen,  but  one  should  ligate  the  cystic  artery  separately. 
Overcasting  of  the  transverse  section  of  the  cystic  duct.  Tam- 
ponade down  to  the  suture  with  sterile  gauze.  This  latter 
brought  out  of  the  upper  angle  of  the  wound.  Closure  of  the 
abdominal  wound  by  through  and  through  silk  sutures.  Dura- 
tion of  operation,  i  ^  hours.      Good  chloroform  anaesthesia. 

The  course  was  unexceptional  ;  patient  never  had  fever,  and 
very  quickly  lost  her  jaundice,  so  that  a  fortnight  after  the 
operation  no  more  bile  pigment  was  demonstrable  in  the  urine. 
The  appetite  was  always  good,  the  stools  of  normal  color  and 
regular.  In  good  condition  of  strength,  the  patient  left  the  clinic 
on  the  31.  12.  98. 

With  the  rare  complication  of  purulent  cholecystitis  zvith  chronic 
lithogenous  obstruction  of  the  clioledochus  we  have  to  do  in  the 
following  4  cases,  which  offer  to  the  beginner  marked  difficulties 
in  diagnosis,  since  one  finds  in  chronic  obstruction  of  the  chole- 
dochus  by  stone  the  gall-bladder  contracted  and  usually  unim- 
plicated  in  an  inflammatory  process. 

(a)  Mrs.  A.,  46  years,  from  Aderstedt.  Entered,  21.8.  96. 
Operation,  26.  8.  96.  Cystostomy.  Secondary  choledochot- 
omy.      Discharged,  27.  10.  96.      Cured. 

Amnesis. — Patient,  who  has  suffered  for  four  years  from  gall- 
stones, has  been  very  ill  for  a  week.  Her  previous  attacks, 
about  four  each  year,  consisted  only  of  cramps  in  the  stomach, 
without  jaundice  ;  this  time  there  occurred  violent  pains  in  the 
back  with  fever  and  indescribable  painfulness  in  the  region  of  the 
liver.  The  attending  physician.  Dr.  Klavehn,  made  the  diagno- 
sis of  sero-purulent  cholecystitis  and  advised  prompt  operation. 
The  symptoms  and  the  condition  of  the  gall-bladder  (large  gall- 
bladder) agreed  with  the  diagnosis,  yet  the  jaundice  made  me 


254  GALLSTONE  DISEASE. 

doubtful.  On  this  account  we  waited  until  the  26.  2.,  but  the 
jaundice  did  not  vary,  the  general  condition  did  not  improve,  the 
fever  rose  ahvays  higher.  On  this  account  on  the  26.  8.  cystos- 
tomy.  Purulent  cholecystitis.  In  the  neck  of  the  gall-bladder 
a  walnut-sized  stone.  Removal  through  the  fistula.  Duration 
of  the  operation,  40  minutes.  One  had  to  abstain  from  a  revision 
of  the  choledochus  since  the  patient  was  very  weak  and  with 
putrid  pus  the  incision  of  the  choledochus  could  not  yet  be  w^ell 
done.  During  the  first  few  days  no  bile  escaped,  only  mucus  ; 
the  temperature  fell  to  37.5°.  On  the  3d  day  profuse  escape  of 
bile,  which  held  on  continuously.  On  the  5.,  8.,  12.,  9.,  plugging 
experiment.  Afterwards  always  colic,  fever,  vomiting.  Stone 
in  the  choledochus  probable.  On  the  27.  9.  choledochotomy. 
One  hazelnut-sized  stone  in  the  supraduodenal  part.  Opening 
of  the  abdomen  in  the  median  line.  Gauze  in  the  gall-bladder. 
Many  adhesions.  Gall-bladder  served  as  a  guide  to  the  chole- 
dochus. Incision.  Suture  (7  sutures).  Tamponade.  Dura- 
tion of  the  operation,  ij4  hours.  Smooth  course.  The  bile  ex- 
cretion gradually  diminishes,  and  already  ceases  completely  18. 
10.      On  the  22.  10.  discharged  well. 

(b)  Miss  M.  B.,  27  years,  from  Eisenach.  Entered,  24.  11. 
97.  Operation,  26.  11.  97.  Ectomy  and  choledochotomy.  Dis- 
charged, 30.  12.  97.      Cured. 

Parents  of  the  patient  are  dead  ;  of  five  brothers  and  sisters 
four  are  living  in  good  health.  Patient  in  childhood  suffered 
from  distress  in  the  stomach,  which  later  (1886)  turned  into 
cramps  of  the  stomach.  Almost  four  years  ago  there  occurred 
an  attack  of  cramps  in  the  stomach  w^ith  jaundice.  The  seat  of 
the  pain  was  in  the  median  line  above  the  navel.  In  the  begin- 
ning the  pain  lasted  two  hours,  later  up  to  two  days.  Attacks 
with  jaundice — second  in  1896 — occurred  to  about  the  number 
of  eight.  In  April  and  May,  1897,  the  patient  underwent  a  cure 
at  Carlsbad,  which  has  as  a  result  that  the  colics  disappeared, 
but  on  the  other  hand  there  remained  the  feeling  of  pressure, 
the  sticking  and  the  pains  in  the  back.     The   lack  of  ability  to 


CLINICAL  AND  OPERATION  HISTORIES.  255 

pursue  her  vocation  as  teacher  led  her  to  enter  the  cHnic  ;  Prof. 
Seydel  of  Jena  had  in  October,  1897,  advised  the  patient  to 
submit  to  operation. 

Status  Praesens. — Moderately  large,  spare  patient  with  pro- 
nounced jaundice.  Heart  and  lungs  normal,  stools  perfectly 
pale,  in  the  urine,  however,  relatively  little  bile  pigment.  Under 
anaesthesia  one  feels  a  hard  tumor  extending  from  the  right  to 
the  median  line  and  reaching  even  to  the  navel. 

Diagnosis. — Cholelithiasis  and  chronic  empyema  of  the  gall- 
bladder.    Stone  in  the  choledochus. 

Operation. — Chloroform  anaesthesia,  about  120  gr.,  duration 
2  hours  (without  introduction  of  anaesthesia  and  dressing,  i  ^ 
hours).  Longitudinal  incision  in  the  right  rectus  abdominal 
muscle  of  about  8  cm.  One  finds  the  gall-bladder  distended. 
On  puncture  reddish  thick  pus  was  evacuated — chronic  em- 
pyema. After  incision  of  the  gall-bladder  one  removed  9  stones, 
the  loth  plugged  the  cystic  duct,  but  let  itself  be  pushed  on  into 
the  gall-bladder  and  be  removed  with  forceps.  The  choledo- 
chus is  dilated  to  the  size  of  the  small  intestine  ;  it  was  first 
recognized  by  assistance  of  an  exploratory  puncture  of  its  con- 
tents. Behind  the  duodenum  a  large  stone  (almost  walnut  size) 
lay  in  the  choledochus.  It  does  not  yield  to  the  pressure  of  the 
finger,  on  that  account  incision  into  the  supraduodenal  part  of 
the  choledochus.  The  left  index  finger  was  introduced,  with 
the  right  hand  upon  the  abdominal  walls,  the  stone  was  dis- 
lodged by  the  bimanual  procedure  and  pushed  high  up,  so  that 
it  was  possible  to  seize  the  concretion  with  a  forceps  and  extract 
it.  Suture  of  the  incision  of  the  choledochus.  The  gall-bladder 
on  account  of  the  disease  of  its  walls  was  extirpated.  The  cystic 
duct  stump  was  overcast.  Gauze  tampon.  The  abdominal 
wound  is  left  open  in  the  middle,  elsewhere  sutured.  Skin 
wound  unsutured.  The  stones  in  the  gall-bladder  are  from  pea 
to  hazelnut  size,  the  stone  in  the  choledochus  almost  walnut 
size.  The  course  is  very  good  (highest  evening  temperature 
37.9°).     On   the   30.   12.  97  the   patient  is   discharged   to  her 


256  GALLSTONE  DISEASE. 

home  with  a  good  granulating  wound  and  the  injunction  to  have  | 
it  dressed  there. 

Remarks. — The  bimanual  procedure  practiced  in  this  case 
made  unnecessary  the  separation  of  the  duodenum  and  its  being 
pushed  to  the  left  for  the  purpose  of  incision  of  the  retroduod- 
enal  part  of  the  ductus  choledochus. 

(c)  Mrs.  D.  K.,  45  years,  wife  of  mason,  from  Schlanstedt. 
Entered,  27.  1.99.  Operation,  29.  i.  99.  Ectomy.  Choledo- 
chotomy.      Discharged,  5.  3.  99. 

Amnesis. — Nothing  particular  in  family  history.  Patient  in 
her  youth  somewhat  sickly,  married  at  22  years,  mother  of  five 
children,  of  which  two  were  stillborn.  Suddenly,  six  years  ago, 
the  patient  had  an  attack  of  cramps  in  the  stomach  of  several 
hours'  duration  ;  this  recurred  several  times.  It  was  attended 
by  vomiting  and  jaundice  of  short  duration.  Afterwards  Mrs. 
K.  was  healthy  until  in  November,  1898,  again  colics  occurred, 
however  of  much  more  violent  kind.  At  first  the  colics  occurred 
every  two  or  three  days,  in  the  last  fortnight  daily.  For  a  fort- 
night Mrs.  K.  has  been  }'ellow.  Stools  were  clay-colored  after 
the  occurrence  of  jaundice  ;  they  are  at  present  loam-colored, 
the  urine  is  brown.  After  purgation  (since  the  28th  of  this 
month)  the  patient  has  been  free  from  pain.  Dr.  Herbst  sends 
the  patient. 

Status  Praesens. — Medium-sized,  pretty  powerful  woman, 
slightly  jaundiced.  Liver  but  little  enlarged,  gall-bladder  not 
clearly  to  be  felt  on  account  of  the  tension  of  the  abdominal 
muscles,  only  a  sense  of  resistance  in  its  region.  Urine  free 
from  albumin  and  sugar,  contains  bile  pigment. 

Diagnosis. — Acute  sero-purulent  cholecystitis,  owing  to  pur- 
gation on  the  decline  ;  stones  in  the  gall-bladder,  stones  on  the 
passage  through  the  choledochus. 

Operation. — Longitudinal  incision  in  the  right  rectus  ab- 
dominal muscle,  extended  upwards  along  the  ribs  to  the  ensi- 
form  process.  Wandering  liver,  general  enteroptosis.  Gall- 
bladder extends  a  thumb's  breadth   beyond  the  lower  border  of 


CLINICAL  AND  OPERATION  HISTORIES.  257 

tlie  liver,  fresh  adhesions  with  the  stomach  and  duodenum,  the 
serous  membrane  oedematous.  Separation  of  the  adhesions,  ex- 
posure of  the  choledochus.  A  concretion  is  felt  in  its  pancreatic 
portion.  It  is  possible  after  division  of  the  lesser  omentum  to 
push  this  into  the  supraduodenal  position  of  the  duct.  Incision 
upon  the  stone.  Extraction.  Stone  cherry-sized  and  granular. 
Opening  of  the  gall-bladder  ;  it  contains  pus  and  two  mulberry 
stones.  Difficult  separation  of  the  gall-bladder  from  the  liver. 
Separate  ligature  of  the  cystic  artery.  Division  of  the  cystic 
duct  into  the  choledochus  discloses  that  the  ducts  for  a  little  dis- 
tance run  parallel  to  one  another.  Suture  of  the  incision  into 
the  choledochus,  suture  of  the  cystic  duct  with  catgut.  Hepa- 
topexy.  Tamponade.  Closure  of  the  abdominal  wound  with 
Spencer  Wells'  suture.      Duration  almost  2  hours. 

With  extraordinary  clearness  were  in  this  case  developed  the 
inflammatory  processes  which  disclosed  themselves  by  the 
oedema  of  the  serosa  of  the  gall-bladder,  especially  on  the 
cystic  duct.  The  stone  in  the  choledochus  behind  the  duo- 
denum was,  after  division  of  the  omentum  minus,  easily  pressed 
into  the  supraduodenal  portion,  whence  its  extraction  was  easy. 
Especially  with  the  enteroptosis  was  the  operation  far  from  diffi- 
cult, the  choledochus  lay  so  near  the  surface  that  one  might  have 
made  the  suture  extra-peritoneally  with  ease  ;  it  was  hardly  5 
cm.  distant  from  the  anterior  wall  of  the  abdomen.  There  was 
no  reason  for  drainage  of  the  hepatic  duct,  a  giving  away  of  the 
suture  would  have  done  no  harm  by  reason  of  the  tampon. 

Course  good.  Suture  of  the  choledochus  held  ;  no  pains. 
On  the  3d  day  signs  of  acute  dilatation  of  the  stomach.  Con- 
siderable vomiting,  small  pulse,  etc.  No  fever.  Outwashing  of 
stomach.  Improvement  afterwards.  Dressings  changed  on  the 
14th  day.  Sutures  and  tampon  removed.  Wound  looks  very 
well.      General  condition  excellent.      Discharged  cured. 

(d)  Mr.  H.,  42  years,  merchant,  from  Berlin.  Entered,  24. 
8.  96.  Open,  26.  8.  96.  Choledochotomy.  Cystocotomy. 
Cystostomy.      Discharged  cured,  30.  9.  96. 


258  GALLSTONE  DISEASE. 

Amnesis. — Father  of  four  children  ;  has  already  had  gall- 
stone disease  7  years  ;  has  made  use  of  different  **  cures  "  in 
Carlsbad  and  Neuenahr  with  only  temporary  success.  Since  the 
beginning  of  August,  1896,  he  has  been  in  Hahnenklee  (Hartz) 
for  the  restoration  of  his  health.  He  was  there  attacked  with 
severe  colic  pains  ;  the  jaundice,  which  had  varied  in  its  intensity 
for  about  4  weeks,  became  somewhat  less  after  a  stay  of  6  days. 
On  the  7.  8.  the  patient  was  attacked  with  very  severe  pain  in 
right  upper  abdomen  and  with  fe\er.  He  loses  his  appetite,  has 
much  vomiting  and  difficult  stool.  After  a  week  the  fever  left, 
but  the  dull  pains  in  the  region  of  the  gall-bladder  persisted. 
He  left  his  bed  up  till  the  20.  8.,  but  was  again  obliged  to  take 
to  it,  since  fever  and  jaundice  appeared  anew  ;  the  pains  in  the 
right  side  also  increased  in  intensity.  He  had  himself  first  taken 
to  Goslar,  and  had  the  intention  of  having  an  operation  in  Ber- 
lin, but  he  preferred,  since  his  condition  was  so  feeble,  to  come 
to  Halberstadt. 

Status  Praesens. — Large  man,  markedly  emaciated.  Pro- 
nounced jaundice.  Gall-bladder  to  be  felt  as  a  tumor.  Liver 
enlarged,  in  the  median  line  and  especially  over  the  gall-bladder 
marked  pain  on  pressure.  In  urine  bile  pigment  and  1.2  per 
cent,  sugar.  Temperature,  39.3°  C.  on  the  24.  8.  ;  on  the  25. 
8.,  37.8°  C,  morning;  evening,  39.1°  C.  Pulse  small,  about 
100  beats. 

Diagnosis. — Chronic  obstruction  of  the  choledochus.  Acute 
purulent  cholecystitis.      (Carcinoma  is  to  be  excluded.) 

Operation,  26.  8.  96.  Chloroform,  i  ^/j^ -hour  operation.  Gall- 
bladder large,  in  it  pus,  and  in  its  neck  an  almost  walnut-sized 
stone.  Aspiration  of  the  contents  of  the  gall-bladder  after  the 
separation  of  some  firm  adhesions  between  the  gall-bladder  and 
colon  or  omentum.  Almost  pure  pus.  The  stone  in  the  neck 
of  the  gall-bladder  does  not  yield,  hence  cysticotomy.  (7 
sutures.)  In  the  choledochus,  after  considerable  search,  a  sec- 
ond somewhat  smaller  stone  was  found,  which  was  removed  b\' 
a  cllole(lochotom\^      No  other  stone  to  be  detected.      Suture  of 


CLINICAL  AND  OPERATION  HISTORIES.  259 

the  incision  in  choledochus  by  6  sutures.  No  tamponade  of  the 
cystic  and  common  duct  sutures.  Cystostomy.  On  the  even- 
ing of  the  day  of  operation  the  temperature  is  38.6°  ;  pulse  very 
fast  (130  beats).  On  the  27.  8.,  37.7°  C.  ;  pulse,  100.  Peri- 
stalsis. Glycerine  enemata.  Flatus  passes.  No  more  vomiting. 
Evening,  38.1°  C.  ;  then  normal.  Slight  flow  of  bile  from  the 
biliary  fistula.  Dressings  changed  on  7th,  8th  and  loth  days. 
The  secretion  stopped.  The  abdominal  wound  did  not  heal  by 
first  intention,  but  gaped  at  the  lower  end.  Tamponade  with 
sterile  gauze.  On  the  26.  9.  the  wound  is  firmly  healed.  Patient 
has  gained  7  pounds  in  weight,  and  looks  healthy.  Not  a  trace 
of  jaundice.  He  left  the  clinic  on  the  30.  9.  with  the  advice  to 
undergo  an  after-cure  at  Carlsbad. 

In  the  following  case  a  stone  stuck  with  its  smaller  portion  in  the 
cystic  duct,  whilst  its  larger  part  protruded  into  the  choledochus, 
and  finally  caused  tlic  symptoms  of  chronic  litJiogeiwjis  obstruction 
of  the  cliolcdoclius.  Very  instructive  is  the  history,  by  reason  of 
which  there  could  be  absolutely  no  more  doubt  of  the  diagnosis 
*'  gallstones  in  the  choledochus." 

Geheim.  Med.  Rath,  Prof.  Dr.  Sch.,  60  years,  from  Halle  a. 
S.  Entered,  24.  5.  97.  Open,  26.  5.  97.  Choledochotomy. 
Discharged,  12.  7.  97.      Cured. 

Amnesis. — This  the  patient  himself  had  the  kindness  to  write 
down.  It  is  as  follows  :  "  Mother  and  a  brother  suffered  from 
gallstone  colic.  The  first  was  cured  by  2  visits  to  Carlsbad  and 
died  at  an  advanced  age  from  an  heart  affection  with  dropsy, 
without  any  hereditary  taint  from  cancer  or  tuberculosis.  Always 
temperate,  but  most  sedentary  life.  1871-72,  periosteal  suppu- 
ration on  the  left  femur  immediately  above  the  knee-joint.  Since 
1877,  moderate  chronic  bronchial  catarrh,  with  emphysema. 
Since  1880,  insomnia.  In  1888  a  very  severe  and  two  light 
attacks  of  kidney  coHc  (left).  1891,  violent  attack  of  colic,  the 
cause  of  which  remained  undetermined  (intestine  or  liver?);  Carls- 
bad Miihlbrunnen.  1893,  in  the  middle  of  May,  an  attack  of 
colic  (gallstone?)  ;  on  the  25.  5.,  burning  of  gullet  and  cesoph- 


26o  GALLSTONE  DLSEASE. 

agus  and  stomach  with  spirits  of  ammonia.  Fortnight  in  bed. 
13-  ^-  93>  attack  of  coHc.  Beginning  of  March,  1894,  attack 
of  coHc.  In  1895,  severe  and  Hght  attacks  of  colic,  frequently 
recurring  (16.  2.,  22.  2.,  27.  2.,  20.  4.,  17.  5.,  5.  8.,  15.  9.,  16. 
9.,  17.  9.,  18.  9.,  19.  9.),  each  time  lasting  several  hours  ;  begin- 
ning of  the  pain  usually  in  the  pit  of  the  stomach  or  somewhat 
lower.  Besides  variable  location  of  pain,  now  at  the  left  in  the 
region  of  the  transition  of  the  transverse  into  the  descending 
colon,  now  at  the  right  in  the  lumbar  region,  sometimes  proc- 
talgia. After  the  attacks  occurring  each  night  toward  2  o'clock  5 
times  running  in  September,  there  remained  always  after  eating  dis- 
tress from  pressure  and  fullness  in  the  region  of  the  stomach.  Lit- 
tle appetite  ;  disgust  for  meat.  Stool  usually  constipated,  scybala. 
From  the  23.  12.  95  to  8.  2.  96  febrile  sickness  with  occasional 
temperatures  up  to  39°  in  evening,  usually  between  38.2°  and 
38.5°.  With  this  several  attacks  of  colic  and  inflammation  in 
the  left  shoulder-joint.  lo-i  i.  3.,  coHc  attack.  24.  3.  to  1 1.  4., 
persistent  colic  pains  with  intestinal  paralysis.  Irrigation  by 
rectal  tube  after  several  futile  attempts  brought  forth  many  scy- 
balous masses. 

"In  the  beginning  of  May,  1896,  Prof  L.,  of  Wurzburg,  was 
consulted.  His  diagnosis  was  "  chronic  intestinal  catarrh,  secon- 
dary nervous  dyspepsia,  with  intact  function  of  the  stomach. 
Circumscribed  swelling  of  the  liver  border  in  the  region  of  the 
gall-bladder  (whether  depending  upon  former  gallstone  colic 
attacks?).  Slight  systolic  (accidental)  murmur  at  the  mitral." 
After  the  return  from  Wurzburg,  again  febrile  sickness  from  7. 
5.  to  13.  6.  with  cohc-like  pains  in  the  abdomen,  and  tempera- 
ture 38.3°  and  39.4°.  Afterwards  slowly  recovered  and  again 
took  on  weight.  Relative  good  health  until  the  end  of  1896. 
Persistent  tendency  to  constipation,  sometimes  for  a  few  days 
diarrhoea.  Always  considerable  mucus  in  stools.  Toward  the 
22.  12.  96  there  first  appeared  jaundice,  which  quickly  increased 
and  lasted  in  all  with  variations  6  weeks.  With  it  no  striking 
weakness,  no   complete   loss  of  appetite.      During  this  period  a 


CLINICAL  AND  OPERATION  HISTORIES.  261 

loss  of  bodily  weight  of  about  2  kilo.  From  the  7.  2.  97  again 
bile  colored  stools  and  clear  urine.  14.  2.,  influenza  of  a  week's 
duration,  leaving  behind  an  obstinate  bronchial  catarrh.  On  the 
28.  2.,  again  jaundice,  continuing  this  time  4  weeks.  With  it 
from  the  17.  3.  to  the  31.  3.,  five  irregular  intermittent  febrile 
attacks,  up  to  40.1°  at  highest.  On  3.  4.  again  normal  colored 
stool  and  clear  urine.  In  the  beginning  I  asked  Prof.  Kehr  in 
consultation  with  the  attending  physician,  and  it  is  perhaps  in- 
teresting, with  reference  to  the  condition  at  the  operation  des- 
cribed below,  to  quote  here  verbally  the  written  diagnoses  which 
had  been  given  : 

"  I.  Geh.  Rath.  W.  Probably  gallstones  in  the  choledochus 
and  gall-bladder  (?)  or  catarrhal  jaundice,  with  occasional  ob- 
struction of  the  choledochus. 

''2.  Prof.  K.  Inflammatory  changes  in  the  bile  ducts  up  to  the 
liver  (cholangitis),  perhaps  purulent  collections  in  the  terminals 
of  the  bile  canals.  Cause,  gallstones.  Whether  such  are  now 
present  is  questionable. 

"3.  Prof  G.  Inflammatory  changes  in  the  region  of  the  bile 
ducts. 

'*  4.  Prof  Kehr.  Old  gallstone  disease.  Contracted  gall- 
bladder. Periodic  occurring  cholecystitis  or  cholangitis  (accom- 
panying inflammatory  jaundice).  Adhesive  peritonitis.  Adhe- 
sions between  gall-bladder  and  omentum,  or  colon.  Choledo- 
chus stone  very  improbable.  (Fistula  between  gall-bladder  and 
intestine  ?) 

"During  the  night  from  21.  to  22.  4.  a  fresh  febrile  attack 
up  to  39.5°  without  cohc  pain,  but  after  preceding  feeling  of 
pressure  in  the  right  hypochondrium.  From  24.  4.  to  2.  5., 
relative  well  being.  From  3.-6.  5.,  7.-10.,  13.-15.,  16.,  22., 
23.,  24.,  25.,  repeated  febrile  attacks  (between  39°  and  39.8° 
temperature)  with  violent  colic  pains  and  jaundice.  Long  and 
regularly  continued  examination  of  the  feces  for  stones  had  no 
positive  result,  only  a  single  time  there  was  found  toward  the 
last  collections  of  cholestearin  crystals.  Always  undigested 
muscle  fibers  and  remains  of  plants." 


262  GALLSTONE  DISEASE. 

Status  Prsesens. — Very  much  emaciated,  large  man.  In- 
tense jaundice.  Heart  and  lungs  normal.  In  the  region  of  the 
gall-bladder  very  slight  sensitiveness  to  pressure.  Liver  and 
spleen  not  enlarged.  Urine  contains  besides  bile  pigment  no 
abnormal  constituents,  stools  grey.  Temperature  before  opera- 
tion in  the  evening  raised  (to  39°  C),  pulse  regular,  strong,  74 
beats  in  the  minute.  The  jaundice  is  now  so  intense  that  a  di- 
rect obstruction  of  the  choledochus  must  exist.  The  variations 
of  the  fever  are  very  characteristic  of  obstruction  of  the  chole- 
dochus. 

Diagnosis  is  made  of  obstruction  of  the  choledochus  by  stone 
from  the  course  of  the  disease  in  April  and  May. 

Operation  on  26.  5.  97.  Chloroform  anaesthesia.  Longitu- 
dinal incision  in  right  rectus  abdominal  muscle  from  curve  of 
ribs  to  level  of  the  navel.  Opening  of  the  belly.  Gall-bladder 
is  small,  contracted,  lies  embedded  in  a  wall  of  adhesions  which 
go  to  the  transverse  colon.  The  separation  of  the  adhesions 
succeeds  with  difficulty.  By  means  of  a  Pravaz  syringe  an  ex- 
ploratory puncture  of  the  gall-bladder  is  made  ;  it  discloses 
muddy  serous  fluid.  At  the  opening  of  the  cystic  duct  into  the 
choledochus  there  is  lodged  a  stone  i  ^  cm.  long,  )4  cm.  broad, 
the  smaller  part  in  the  cystic  duct,  narrowing  the  common  duct. 
This  was  shoved  into  the  choledochus  and  was  thence  by  incision 
removed.  Since  the  gall-bladder  was  almost  obliterated,  and  be- 
sides now  extirpation,  a  very  questionable  procedure  in  this  case 
would  be  for  the  patient  a  far  too  depressing  procedure,  it  was 
let  alone.  The  incision  in  the  choledochus  was  closed  with  5 
sutures.  Now  followed  partial  closure  of  the  wound.  A  long 
tampon  was  introduced  down  to  the  choledochus.  Dressing. 
Duration,  i  J/^  hours.  The  stone  might  have  been  cut  out  of  the 
cystic  duct  also  ;  into  the  gall-bladder  it  could  not  be  pushed. 
The  supraduodenal  part  of  the  choledochus  was  more  convenient 
for  an  incision,  and  besides,  the  stone  lay  for  the  most  part  in 
the  choledochus.  The  course  of  the  wound  was  the  most  favor- 
able to  be  imagined  ;  the  highest  temperature   reached  S?-?'^- 


t.  CLINICAL  AND  OPERATION  IlLSTORIES.  263 

For  the  first  few  days  the  patient  suffered  from  vomiting  and 
pretty  severe  singultus.  Ah'eady  36  hours  after  operation  pas- 
sage of  flatus,  l^elly  soft,  not  distended.  On  the  31.5.  first 
stool  of  completely  normal  color,  occasional  scybala^.  On  the 
5.  6.  the  dressings  were  changed,  the  wound  cavity  looked  to 
be  granulating  well,  this  diminished  with  extraordinary  rapidity 
in  the  next  few  days.  The  jaundice  paled  more  and  more,  the 
itching  of  the  skin  disappeared.  vSeventeen  days  after  the  opera- 
tion no  more  bile  pigment  was  to  be  detected  in  the  urine.  Stools 
brown,  contain  no  mucus,  only  few  undigested  muscular  fibers. 
Patient  increased  several  pounds  in  weight,  his  general  condition 
was  so  good  that  he  could  be  discharged  on  the  12.  7.  as  cured. 
There  was  only  still  a  small  strip  of  granulations  visible.  Con- 
cerning his  subsequent  condition,  the  patient  gives  the  following 
report  :  "  Discharge  from  the  private  clinic  on  12.  7.  with  almost 
healed  w^ound.  On  at  the  lower  end  of  the  scar  there  clung 
still  a  moist  brown  scab.  In  the  night  of  the  25.  to  26.  7.,  the 
first  time  since  operation,  again  pains  in  the  epigastrium,  lasting 
one  hour. 

"  29.  7.  Removal  of  a  ligature  from  the  lower  end  of  the 
scar.  Slight  attacks  of  pain  in  the  stomach  or  light  attacks  of 
colicky  pains  in  the  left  abdominal  and  lumbar  region  have  since 
still  often  occurred  in  the  night  (for  1-2  hours),  but  so  far 
never  in  severity  and  duration  as  before  operation.  In  all,  from 
12.  7.  97  up  till  to-day  (19.  5.  98)  ten  times.  No  more  febrile 
attacks.  Appetite  and  digestion  are  regular,  no  longer  mucus 
in  stools.  The  discomforts  arising  from  the  at  first  deeply  in- 
drawn, but  now  flattened  scar,  which  in  the  first  few  months 
after  the  operation  were  very  annoying,  have  gradually  dimin- 
ished. In  October,  1897,  there  formed  a  walnut-sized  haemor- 
rhoid,  which  since  has  disappeared.  The  bodily  weight  has 
increased  15  kilogr.  since  the  operation." 

The  increase  in  weight  is  the  best  proof  of  the  success  of  the 
operation  ;  the  appearance  of  the  patient  is  excellent. 

The  following  crsg  of  Jlsnt /a  of  tJic  gall-bladder  a)id  colon  is  in- 


264  GALLSTONE  DISEASE. 

tercstiiig,  since  despite  many  stones  in  the  choledoehus^  jatuidice 
was  ivanting :  this  is  explained  by  the  bile  freely  passing  through 
the  anastomosis. 

Mrs.  M.  K.,  38  years,  wife  of  a  master  mason,  from  Lauter- 
berg  a.  H.  Entered,  28.  ii.  98.  Operation,  30.  1 1.  98.  Cys- 
tectomy, closure  of  a  fistula  between  the  gall-bladder  and  colon. 
Drainage  of  the  hepatic  duct.  Choledochotomy.  Discharged, 
7.  I.  99.      Cured. 

Amnesis. — Mrs.  K.  was  otherwise  healthy,  save  that  for  more 
than  18  years  she  suffered  from  pains  in  the  stomach,  occasional 
vomiting  and  loss  of  appetite.  For  5  years  there  have  occurred 
cramp-like  pains  in  the  region  of  the  stomach  and  right  side,  as- 
sociated with  vomiting,  never  with  jaundice.  The  attacks  lasted 
a  day,  their  frequency  was  very  great.  After  an  oil  ''cure" 
there  was  an  interval  of  a  year,  then  a  Carlsbad  cure  at  home  in 
a  short  time  brought  two  years'  peace.  In  the  last  two  years 
now  and  then  cramp  attacks,  especially  pains  in  the  back,  very 
disturbed  appetite,  weakness.  The  last  attack — middle  of  No- 
vember of  this  year — was  especially  violent,  and  lasted  2  days. 
At  the  suggestion  of  Dr.  Kleiber  the  patient  comes  hither. 

Status  Praesens. — Medium-sized,  not  very  strong  woman, 
somewhat  spare.  No  jaundice.  Nothing  especial  in  organs. 
Liver  extends  very  low  in  the  abdomen  (enteroptosis).  In  the 
region  of  the  gall-bladder  marked  painfulness.  No  bile- 
pigments  in  urine. 

Diagnosis. — Stones  in  the  gall-bladder,  dislocated  liver. 

Operation. — 30.  11.  98.  Longitudinal  incision  in  the  right 
rectus  abdominal  muscle.  Large  liver.  Gall-bladder  adherent 
to  colon.  Fistula  between  gall-bladder  and  colon.  Separation. 
Closure  of  the  hole  in  colon  by  7  sutures.  Hole  in  the  gall- 
bladder clamped.  In  the  gall-bladder  muddy  bile  and  stones. 
In  the  choledochus  and  hepaticus  a  series  of  stones  to  be  felt. 
Opening  of  the  choledochus.  The  bile  from  the  hepatic  duct  is 
collected  in  a  sterilized  flask  for  bacteriological  examination. 
(See   result  below.)     Removal   of  five  stones  from  the  hepatic 


CLINICAL  AND  OPERATION  HISTORIES.  265 

duct.  The  bifurcation  is  easily  felt  by  the  finger  introduced  in 
the  duct.  Tedious  extraction.  Offensive  muddy  bile  escapes. 
Drainage  of  the  hepatic  duct  after  ectomy.  The  tube  was  intro- 
duced about  4  cm.  deep  in  the  hepatic  duct  and  firmly  sutured. 
Extensive  circular  tamponade.  Closure  of  the  abdominal  wound 
by  through  and  through  silk  sutures.  Gauze  brought  out  of 
wound.  Duration,  2  hours.  Pulse  moderate.  Afebrile  course. 
In  24  hours  about  800  ccm.  of  bile  escapes.  On  the  eighth  day 
change  of  dressings.  The  bile  is  still  always  evil-smelling  and 
muddy.  (Still  stones  in  the  hepaticus.)  Outwashing  of  the 
hepatic  duct  with  physiological  salt  solution.  The  tube  was 
boiled  and  reintroduced.  Tampon.  Patient  eats  well  and  feels 
well.  On  the  9.  12.  second  change  of  dressings.  Still  con- 
stantly muddy  and  offensive  smelling  bile  escapes  from  the 
hepaticus.  The  hepaticus  is  tamponed  with  gauze,  so  that 
the  bile  will  collect  behind  it  and  move  the  stone  down. 
In  fact  on  the  succeeding  day  it  is  possible  by  outwashing  of 
the  hepaticus  to  remove  the  stone,  which  one  clearly  felt  in  the 
right  hepatic  duct  immediately  behind  its  division.  Probing  of 
the  left  hepatic  duct  very  easy.  New  tampon.  The  choledo- 
chus  is  patent.  Stools  naturally  totally  uncolored.  The  sound- 
ing and  outwashing  of  the  hepaticus  is  thus  carried  out,  the  wall 
of  the  hepaticus  is  seized  with  a  forceps,  and  thus  the  duct  is 
elevated.  One  thus  sees  clearly  into  the  hepaticus,  can  sound 
the  choledochus,  and  is  even  in  position  to  introduce  the  index 
finger  as  far  as  the  bifurcation  of  the  hepaticus.  Up  till  23.  12. 
daily  dressing  with  outwashing  of  the  hepaticus,  since  the  bile 
is  still  constantly  muddy  and  offensive.  On  the  24.  25.  12.  the 
dressing  is  not  wet  with  bile,  stools  of  good  brown  color.  No 
fever,  excellent  general  condition.  Change  of  dressings  on  the 
30.  12.,  wound  is  closed  at  the  bottom,  no  more  bile  escapes. 
Since  then  rapid  recovery.  Discharged  in  blooming  health 
7.  I.  99. 

The  fresh  examination  of  the  bile  obtained  at  the  operation 
discloses,  as  the  Pathological  Institute  of  Gottingen  writes,  the 
presence  of  the  most  different  bacteria  : 


266  GALLSTONE  DISEASE. 

1.  Short  rod,  arranged  variously  in  groups,  most  numerously 
present. 

2.  Oval  plump  rods  and  double  rods. 

3.  Threadlike  forms  of  variable  appearance. 

4.  Occasional  cocci  and  diplococci. 

On  cultivation  upon  gelatine  there  grow  in  great  numbers 
colonies  of  the  bacterium  coli. — Upon  agar  with  the  bacterium 
coli  a  kind  of  coccus  also. — The  bile  contains  a  rich  bacterial 
flora,  in  which  the  bacterium  coli  assumes  the  first  place. — Con- 
cerning the  nature  of  the  coccus  further  cultivations  will  first 
give  a  conclusion.  Concerning  the  other  bacteria  no  diagnosis 
is  possible,  since  no  growth  has  thus  far  occurred  on  the  plates 
employed. 

Remarks. — The  fistula  between  the  gall-bladder  and  colon 
was  the  reason  that  the  diagnosis  of  a  choledochus  stone  was 
not  made.  The  bile  could  escape,  although  the  choledochus 
was  plugged  with  stones.  If  one  in  such  a  case,  in  which  the 
5ile  actually  stinks,  should  perform  a  choledochotomy  with 
suture,  one  would  hardly  be  able  to  expect  a  success.  The 
drainage  of  the  hepaticus  is  under  all  circumstances  demanded. 
Whether  it  succeeds  depends  upon  how  far  the  infection  has 
advanced,  and  whether  the  cholangitis  is  already  diffuse  or  lim- 
ited only  to  the  great  branches  of  the  hepatic  duct. 

A  complete  obliteratio?t  of  the  choledochus  I  have  seen  in  only  a 
single  very  interesting  case. 

Mrs.  K.  M.,  33  years,  wife  of  a  laborer,  from  Wegeleben. 
Entered,  29.  i.  99.  Operation,  31.  i.  99.  Cystectomy.  He- 
paticus drainage.      Discharged  cured,  12.  3.  99. 

Amnesis. — Mother  died  of  cancer  of  the  liver,  father  is 
healthy,  brother  and  sister  are  healthy.  Mrs.  M.  was  formerly 
healthy,  married  at  22  i^  years,  mother  of  three  healthy  chil- 
dren. Two  or  three  years  ago  colicky  pains,  no  cramps  in  the 
stomach.  A  fortnight  before  Christmas  (1898)  pains  of  a  cramp- 
like character  in  the  pit  of  the  stomach  and  in  the  back,  after- 
wards jaundice.     Then  an  attack  at  Christmas.     The  still  exist- 


CLINICAL  AND  OPERATION  IILSTORIES.  267 

ing  jaundice  increased.  Fortnight  later  third  attack.  The  2 2d 
of  January  fourth  attack.  The  jaundice,  which  had  diminished, 
increased,  and  exists  for  example  in  high  degree.  The  stools 
are  light,  clay-colored.  The  urine  is  beer-brown.  Appetite 
poor.  Vomiting  did  not  occur.  Patient  has  lost  about  5  pounds. 
Dr.  Rennebaum  sends  the  patient. 

Status  Praesens. — Small,  weak,  very  jaundiced  woman.  Or- 
gans healthy,  save  the  liver,  which,  especially  in  the  right  lobe, 
is  much  enlarged.  Gall-bladder  not  to  be  felt.  Urine  free  from 
albumin  and  sugar,  contains  considerable  bile  pigment. 

Diagnosis. — Inflammatory  pancreas  tumor  in  consequence  of 
previous  inflammation  in  the  gall-bladder  and  choledochus  which 
is  to  be  ascribed  to  st-ones  ;  possibly  still  stones  in  the  choledo- 
chus ;  jaundiced  congested  liver  (ulcus  duodeni  ?). 

After  that,  on  the  30.  i.,  the  patient's  temperature  in  evening 
had  reached  38.5°  C.  ;  the  operation  was  undertaken  on  the  31.  i. 
Gall-bladder  large,  extensively  adherent  to  omentum  and  colon. 
In  the  gall-bladder  pus  and  2  stones.  In  the  cystic  duct  a 
larger  stone,  which  occasioned  a  complete  obstruction  of  the 
choledochus.  It  had  probably  caused  an  ulcer,  so  that  at  the 
entrance  of  the  cystic  duct  the  common  duct  was  completely 
obliterated.  Toward  the  duodenum  clear,  purulent  mucus. 
Choledochus  was  dilated  to  a  cyst.  Incision.  Extraction  of  a 
stone.  The  structure  in  the  choledochus  was  divided,  and  by 
excision  of  the  choledochus  the  passage  was  restored.  The 
posterior  wall  of  the  completely  severed  choledochus  was  su- 
tured. Procedure  just  as  with  suture  of  the  urethra  after  ure- 
throtomia  externa.  Then  drainage  of  the  hepatic  duct.  Tam- 
ponade after  excision  of  the  ulcerated  gall-bladder.  It  was  re- 
markable that  no  bile  flowed  out  of  the  hepaticus.  The  liver  is 
so  insufficient,  the  liver-cells  so  disturbed  in  their  function  that 
they  secrete  no  bile.  Some  hard  places  in  the  pancreas.  We  con- 
sidered whether  it  was  not  better  to  do  a  choledocho-duodenos- 
tomy,  but  we  refrained  from  it,  since  we  hoped  that  the  changes 
in  the  pancreas   were  of  inflammatory  origin.     The   slit  in  the 


268  GALLSTONE  DISEASE. 

omentum  minus,  which  wc  made  to  expose  the  pancreas  head, 
was  again  closed  with  sutures.  The  tube  in  the  hepatic  duct 
entered  5  cm.,  and  was  fixed  by  a  suture.  Tampon  all  around 
it.  Duration  of  the  operation,  ij4  hours.  Good  anaesthesia 
with  chloroform. 

The  diagnostic  difficulties  in  this  case  were  considerable;  an 
obstruction  from  a  stone  was  improbable,  since  the  jaundice  was 
of  such  a  high  grade.  A  total  obstruction  must  exist.  Of  an 
obliteration  or  stricture  of  the  duct,  such  as  was  found  at  the 
operation,  no  one  had  thought:  A  disease  of  the  pancreas  came 
sooner  into  consideration. 

Course. — Never  fever,  icterus  very  slowly  disappeared,  which 
is  to  be  ascribed  to  the  long  duration  of  the  disease,  by  which 
the  liver  cells  were  gravely  affected.  From  the  fistula  also  but 
little  bile  escaped,  although  the  drainage  worked  well.  First 
change  of  dressings  on  the  twelfth  day.  Removal  of  sutures. 
First  intention.  General  condition  good,  appetite  slight.  Daily 
dressings.  With  slight  jaundice  the  patient  is  on  the  12.  3.  dis- 
charged. The  wound  is  closed  since  the  10.  3.  Appetite  now 
good,  stools  brown.      General  condition  better. 

T/ic  cJwlangitis  diffusa  punilcnta  of  the  smallest  branches  of 
the  hepaticus  always  leads  to  death,  whilst  an  uiflamniatioii  in 
the  large  branches  of  the  hepaticus  can  be  cured  by  drainage  of 
the  hepaticus.  To  diagnosticate  whether  already  a  cholangitis 
diffusa  exists  or  not  is  difficult.  In  general  severe  general  symp- 
toms (small  pulse,  high  fever,  septic  condition)  point  to  an  ex- 
tended inflammation,  yet  patients,  in  whom  the  infection  is 
hmited  to  the  large  branches  of  the  hepaticus,  may  convey  the 
impression  of  great  gravity.  A  classical  example  in  this  connec- 
tion is  the  following  case  : 

Mrs.  M.  H.,  26  years,  wife  of  a  gardener  from  Quedlinburg. 
Entered,  24.  4.  97.  Operation,  26.  4.  97.  Ectomy,  choledochot- 
omy,  drainage  of  the  hepaticus.  Discharged,  31.  5.  97.  Cured. 
The  patient  sent  by  Dr.  Steinbriick  for  operation  is  the  mother 
of  a  healthy  child.      In  the  year  1893  she  had  for  the  first  time 


CT.INICAL  AND  OPERATION  HISTORIES.  269 

gallstone  colic  with  vomiting,  but  without  jaundice.  Attacks 
of  this  sort  recurred  in  the  beginning  every  three  months,  then 
there  was  a  pause  of  a  year,  until  they  in  the  year  1896  recurred 
more  violently  and  frequently,  about  every  four  weeks.  Jaun- 
dice appeared  for  the  first  time  at  Christmas,  1896,  and  lasted 
for  three  weeks  with  varying  intensity.  The  last  very  violent 
colic  occurred  in  the  beginning  of  April,  1897  ;  the  jaundice  was 
from  the  first  of  the  same  high  degree  ;  on  the  14th  of  April, 
with  a  chill,  the  temperature  rose  to  over  40°  C.  Urine  was 
beer-brown,  the  stools  grey.  Immediately  upon  the  setting  in 
of  the  fever,  which  ten  days  without  remission  morning  and 
evening  reached  the  height  of  40°  C,  the  attending  physician 
advised  operation  ;  but  he  first  on  the  24th  of  April  obtained 
the  consent  of  the  patient  and  her  relatives. 

On  examination  I  obtained  the  following  data :  Lemon- 
yellow,  very  emaciated  woman.  Foetor  ex  ore,  dry  lips,  en- 
crusted tongue.  Heart  and  lungs  normal.  The  liver  extends 
below  to  the  navel.  The  spleen  is  notably  enlarged.  The  whole 
region  of  the  liv^er  is  sensitive  to  pressure,  especially  in  the  pit  of 
the  stomach  and  the  region  of  the  gall-bladder.  Urine  beer- 
brown,  contains  bile  pigment,  little  albumin,  no  sugar.  Stools 
grey,  without  stones.  The  morning  and  evening  temperatures  on 
the  24th  and  25th  of  April  vary  between  39°  and  40.8°  C.  The 
pulse  was  always  small,  soft,  130  beats  to  the  minute.  The 
diagnosis  of  acute  cholecystitis,  and  cholangitis  and  choledocho- 
lithiasis  was  made.  On  account  of  the  miserable  general  con- 
dition and  the  septic  appearance  of  the  patient  I  was  obliged  to 
give  a  bad  prognosis,  yet  to  the  relatives  it  was  clear  that  with- 
out operation  a  cure  was  as  good  as  impossible  ;  on  this  account 
they  asked  for  operation.  This  was  on  the  26th  of  April,  1897, 
undertaken  under  chloroform  anaesthesia.  A  longitudinal  in- 
cision in  the  right  rectus  abdominal  muscle  from  the  curve  of  the 
ribs  downward  opened  the  abdominal  cavity.  The  vessels  were 
ligated  with  redoubled  care  on  account  of  the  well-known  danger 
of  hemorrhage  in  cholaemia.      The  enormously  enlarged  right 


2/0  GALLSTONE  DISEASE. 

lobe  of  the  liv^er  was  on  its  under  surface  intimately  adherent  to 
the  omentum  and  colon.  After  blunt  separation  of  these  ad- 
hesions there  appeared  the  tensely-filled  gall-bladder.  Its  puru- 
lent contents  were  under  the  safeguard  of  well-known  safety 
precautions  aspirated  with  the  Dieulafoy.  Then  the  gall-bladder 
was  opened  and  i6  stones  extracted.  The  walls  of  the  gall- 
bladder are  so  rotten  and  friable  that  an  extirpation  was  neces- 
sary. In  the  cysticus  there  is  still  found  a  firmly-wedged  stone 
which  is  extracted  after  the  incision  of  the  duct.  The  gall- 
bladder is  removed  and  the  spouting  cystic  artery  ligated  sepa- 
rately. From  the  transverse  section  of  the  cystic  duct  one  may 
now  sound  thoroughly  the  hepaticus  and  the  choledochus.  In 
the  latter  large  stones  were  felt,  and  since  it  was  not  possible  by 
forceps  to  remove  them  through  the  cysticus  stump,  the  stump 
was  divided  on  its  median  wall  and  the  division  extended  with 
angular  scissors  about  3  cm.  into  the  choledochus.  Now  four 
stones  the  size  of  hazelnuts  could  be  readily  extracted  from  the 
choledochus.  One  sees  very  clearly  into  the  lumen  of  the 
hepaticus  ;  this  is  so  wide  that  I  could  readily  introduce  my 
index  finger.  The  finger  tip  readily  feels  the  bifurcation  of  the 
two  great  branches  of  the  hepaticus.  Repeated  sounding  of  the 
choledochus  and  the  papilla  of  the  duodenum  does  not  chance 
upon  further  stones.  After  the  removal  of  the  stones  I  con- 
sidered whether  I  should  again  suture  the  incision  in  the  cystic 
and  common  ducts.  Both  could  be  made  conveniently  accessi- 
ble and  the  application  of  the  suture  would  apparently  meet  no 
particular  difficulties.  But  since,  on  account  of  the  cholangitic 
symptoms,  an  extensive  drainage  of  the  biliary  system  seemed 
to  me  to  be  the  chief  aim,  I  refrained  from  suturing  and  made 
direct  drainage  of  the  hepatic  duct  in  the  following  manner  :  A 
long,  very  soft  index-finger-sized  rubber  tube  was  chosen,  which 
was  boiled  in  soda  solution  y^  of  an  hour,  and  corresponded 
exactly  to  the  lumen  of  the  hepatic  duct,  so  that  it  firmly  touched 
its  walls.  This  was  pushed  about  5  cm.  far  into  the  hepaticus 
and  its  point  of  exit  marked  by  a  ver}'  superficial    excision  of  a 


CLINICAL  AND  OPERATION  HISTORIES.  2/1 

piece  of  rubber.  This  mark  served  to  show  whether  the  tube 
still  lay  deep  enough  in  the  hepatic  duct,  for  during  the  further 
operation,  especially  during  the  tamponade,  it  could  be  very 
easily  displaced.  In  order  to  avoid  this  with  certainty,  the 
rubber  tube  was,  moreover,  fastened  by  a  fine  silk  suture  to  the 
stump  of  the  cystic  duct.  The  incision  in  the  choledochus  was 
closed  with  one  row  of  sutures  as  far  as  the  exit  of  the  tube  from 
the  hepatic  duct.  Then  a  thorough  toilet  of  the  field  of  opera- 
tion followed  and  an  extensive  tamponade  about  the  tube.  All 
sutures  of  the  cystic  and  common  ducts  were  covered  with  long 
strips  of  gauze,  and  these  together  with  the  tube  brought  out  of 
the  abdominal  wound.  The  wounded  surface  of  the  liver,  due 
to  the  excision  of  the  gall-bladder,  was  especially  tamponed. 
Then  the  abdominal  wound,  as  far  as  the  protruding  gauze  per- 
mitted, was  closed  by  deep  and  superficial  sutures.  The  opera- 
tion had  lasted  i  3^  hours  ;  the  patient  was  greatly  collapsed  ; 
pulse  very  frequent  and  small.  While  still  on  the  operating 
table  the  patient  received  a  large  subcutaneous  salt  infusion. 

On  the  evening  of  the  operation  bile  already  flowed  profusely 
from  the  tube  into  the  flask  of  3  per  cent,  carbolic  acid  solution. 
Temperature  37.5°  C,  pulse  iio.  On  the  succeeding  morning 
37.2°  C,  pulse  100.  Patient  feels  as  if  newborn.  In  the  first  24 
hours  the  bile  caught  amounted  to  250  gr.,  in  the  second  24  hours 
270  gr.,  then  there  occurred  a  rapid  increase  to  700  and  1000  gr. 
The  slight  excretion  of  bile  in  the  first  few  days  is  to  be  explained, 
in  my  opinion,  first  by  the  very  limited  amount  of  nourishment 
taken,  and  on  the  other  hand  by  a  secondary  inhibition  of  the 
secretion  of  the  bile  on  account  of  the  high  congestion  pressure 
upon  the  liver  cells  ;  for  all  the  bile  which  the  liver  of  the 
patient  produced  was  caught  from  the  tube  and  for  the  first  ten 
days  it  is  certain  not  a  drop  reached  the  intestine.  The  com- 
mon bile  duct  was  during  this  time  entirely  out  of  function,  as 
the  daily  examination  of  the  colorless  stools  demonstrated. 
Nothing  was  done  to  the  dressing  for  ten  days,  then  it  was  re- 
moved, the  tamponing  gauze  softened  by  profuse  irrigation  with 


272  GALLSTONE  DLSEASE. 

normal  salt  solution,  the  tube  was  withdrawn  from  the  hepaticus 
after  the  removal  of  the  gauze,  and  all  the  sutures  of  the  cysti- 
cus  and  choledochus  were  removed.  The  deep  large  wound 
looked  reactionless,  it  was  dried  with  sterile  gauze  and  then 
loosely  tamponed.  In  the  next  ten  days  daily  dressings  were 
necessary,  since  of  course  the  greater  part  of  the  bile  escaped 
into  the  dressing.  But  already  on  the  I2th  and  the  14th  day 
the  stools  began  to  be  colored,  a  proof  that  the  papilla  was 
patent,  and  4  weeks  after  operation  all  the  bile  took  its  usual 
course  into  the  duodenum.  The  general  condition  improved 
each  day,  the  jaundice  and  the  itching  of  the  skin  disappeared, 
and  5  weeks  after  the  operation  the  patient  could  be  discharged 
as  cured  from  my  house  with  an  increase  of  weight  of  10  pounds. 
Extraordinarily  noteworthy  was  in  this  case  the  immediate  fall 
of  temperature  and  the  improvement  of  the  general  condition, 
so  that  already  two  days  after  the  operation  the  septic  appear- 
ance had  completely  disappeared  ;  furthermore,  very  remarka- 
ble is  the  rapid  closure  of  the  incision  in  the  choledochus.  The 
fact  drawn  from  my  experience,  already  related  in  my  book,  that 
fistulae  in  the  choledochus  close  quickly  and  spontaneously,  if 
the  duct  is  patent,  has  proved  itself  also  here.  No  sort  of  an 
injury  to  the  patient  by  reason  of  the  drainage  has  occurred.  I 
had  in  the  beginning  anxiety  lest  the  tube  could  become 
plugged  by  bloodclot,  since,  as  is  well  known,  cholaemic  patients 
are  very  inclined  to  bleed,  and  by  the  irritation  from  the  presence 
of  the  tube  such  a  bleeding  might  easily  be  excited.  A  leaking 
of  the  bile  by  the  tube  into  the  dressing  was  not  observed  ;  it 
was  due  to  the  fact  that  the  soft,  very  thin-walled  rubber  tube 
corresponded  exactly  to  the  lumen  of  the  hepaticus  and  was  quite 
firmly  surrounded  by  its  walls. 

Here  we  had  to  do  not  only  with  a  "  Perialienitis  serosa  "  but 
infectiosa,  and  if  Riedel  thinks  that  such  cases  die  with  or  with- 
out operation,  then  he  is  right  if  we  do  the  choledochotomy 
with  suture.  Such  have  died  with  us.  But  if  Riedel  in  such 
desolate  cases  tries  the  drainage  of  the  hepaticus,  then  will  he 
surely  be  able  to  confirm  the  good  results  obtained  by  me. 


CLINICAL  AND  OPERATION  HISTORIES.  273 

12. 

Chronic  Obstruction  of  the  Choledochus  from  Tumor. 

A  typical  case  of  chronic  obstruction  of  the  clwlcdochiis  by  tumor 
has  been  several  times  seen  by  me,  but  not  again  operated  upon 
since  the  pubHcation  of  my  monograph,  The  Surgical  Treatment 
of  Gallstone  Disease,  1896.  I  regard  the  utility  of  the  chole- 
cystenterostomy  considered  in  that  case  as  very  slight. 

A  typical  case  of  chronic  obstruction  of  the  choledochus  by  tumor 
has  been  described  by  me  on  page  179  of  my  monograph.  I 
here  give  it  again. 

Mrs.  L.,  48  years,  wife  of  an  agriculturist,  from  Stiege.  En- 
tered on  24.  4.  94. 

Amnesis. — Had  as  a  girl  of  18  years  once  cramps  in  the 
stomach,  otherwise  always  healthy.  Mother  of  10  children. 
Menopause  5  years  ago.  Three  months  ago  she  felt  on  lifting 
pain  in  front  of  stomach,  became  jaundiced  14  days  later,  and 
has  always  remained  so.  Real  colics  she  is  said  not  to  have 
had.  Great  emaciation.  Weight  on  the  24.  4.  94  98  pounds 
(formerly  5  years  ago  148  pounds).      No  bleeding. 

Status. — Intense  icterus,  severe  itching  of  skin.  Urine  dark 
brown,  stool  light  yellow.  Liver  as  a  whole  enlarged,  lower 
sharp  liver  border  at  the  level  of  the  navel.  No  protuberances 
on  the  surface  of  the  liver,  no  ascites.  Gall-bladder  as  an  elastic 
but  little  sensitive  tumor  to  be  felt  immediately  under  the  navel, 
between  the  widely  separated  rectus  abdominal  muscles.  Pa- 
tient complains  of  great  weakness,  appetite  is  moderate,  stools 
daily,  but  colorless. 

Diagnosis. — Choledochus  stone  improbable,  since  the  gall- 
bladder is  large.  (With  choledochus  stone  it  is  usually  con- 
tracted.) The  diagnosis  of  the  obstruction  in  the  choledochus 
is  impossible  ;  carcinoma  of  the  pancreas  comes  most  into  con- 
sideration. A  proposed  exploratory  laparotomy  is  accepted  ; 
perhaps  one  may  by  a  cholecystoenterostomy  relieve  the 
23 


2/4  GALLSTONE  DISEASE. 

cholsemia.  If  there  are  stones,  naturally  the  choledochotomy 
comes  first  into  consideration. 

Operation  on  the  26.  4.  94.  The  diagnosticated  condition  is 
correct.  The  very  large  gall-bladder  contains  almost  a  half  liter 
of  clear  bile  but  no  stones.  On  the  choledochus  is  a  ring- 
formed  carcinoma.  On  this  account  cholecystoenterostomy. 
Discharged  on  the  20.  5.  94  almost  free  from  jaundice.  Three 
months  later  she  died  at  her  home  of  cancerous  cachexia. 

Less  typical  was  the  following,  in  which  one  could  just  as  well 
imagine  a  stone  in  the  cholcdochits,  since  violent  colics  had  pre- 
ceded and  the  jaundice  kept  itself  within  moderate  limits. 

Mrs.  H.  N.,  53  years,  court  gardener's  wife,  from  Dessau. 
Entered,  5.  4.  98.  Operation,  7.  4.  98.  Cholecysto-colostomy 
(carcinoma).      22.  4.  98,  died. 

Family  history  without  importance.  Patient  was  always 
healthy  until  the  middle  of  October,  1897,  suddenly  after  eating 
cramp-like  pains  occurred  in  the  pit  of  the  stomach,  which  lasted 
some  half  hour ;  afterwards  Mrs.  N.  was  violently  attacked. 
Vomiting  and  jaundice  did  not  occur.  The  patient  was  com- 
pletely well  until  New  Years,  1897,  when  at  night  at  2  o'clock 
suddenly  there  occurred  a  very  violent  pain  in  the  back,  which 
lasted  a  short  time,  to  continue  itself  as  a  pain  in  the  stomach  for 
some  hours.  Vomiting  and  jaundice  were  not  present.  Five  days 
later  again  occurred  in  the  night  violent  pain  in  the  back  ;  to  this 
was  added  severe  vomiting.  Now  gradually  jaundice  appeared, 
which  was  referred  by  Dr.  Mohs  to  gallstone  disease.  Despite 
the  drinking  of  Carlsbad  Brunnen  the  jaundice  increased.  Pains 
did  not  again  occur  ;  on  the  other  hand,  from  time  to  time  retch- 
ing and  eructations.  The  appetite  gradually  improved.  The 
patient  came  on  the  5.  4.  98,  by  the  advice  of  Dr.  Mohs,  to  the 
clinic. 

Status  Praesens. — In  the  urine  no  albumin,  but  bile  pigment. 
Lungs  and  heart  healthy.  Liver  enlarged.  Gall-bladder  not 
to  be  felt,  yet  sensitive  to  pressure.  Sensitiveness  to  pressure  in 
the  pit  of  the  stomach.  Moderate  jaundice.  Severe  itching. 
Stools  clay-colored.     Pulse  66,  temperature  o7--^'- 


CLINICAL  AND  OPERATION  HISTORIES.  275 

Operation. — Chloroform  anaesthesia,  70  minutes.  Typical 
longitudinal  incision  in  the  right  rectus  abdominal  muscle.  On 
opening  the  belly  one  finds  a  large  adherent  gall-bladder,  so 
that  immediately  there  arose  a  suspicion  of  carcinoma  of  the 
choledochus.  The  intestines  as  well  as  the  transverse  colon 
very  distended.  The  operation  is  made  more  difficult  by  this. 
In  the  gall-bladder  no  stones  are  to  be  felt.  Immediately  at  the 
junction  -of  the  cysticus  is  a  hard  place  felt  in  the  choledo- 
chus, which  at  first  was  taken  for  a  stone,  but  which  on  explora- 
tory puncture  with  a  Pravaz  syringe  showed  itself  to  be  a  tumor. 
An  extirpation  is  out  of  the  question  ;  there  remains  only  the 
possibility  of  an  artificial  communication  of  the  bile  system 
above  the  obstruction  with  the  intestinal  canal.  Therefore  a 
convolution  of  the  bowel  high  up  was  drawn  out,  in  order  to 
join  this  with  the  gall-bladder.  But  it  was  evident  that  there 
was  great  danger  of  the  formation  of  a  kink  in  the  convolution 
by  reason  of  the  great  distension  of  the  colon  ;  on  this  account 
this  plan  was  abandoned  and  a  fistula  formed  between  the  gall- 
bladder and  the  transverse  colon  somewhat  below  the  flexura 
colica  dextra.  This  was  executed  in  the  customary  manner,  and 
was  only  disturbed  by  the  thickness  of  the  walls  of  the  colon. 
Afterwards  the  abdominal  wound  was  closed  by  peritoneal-fascial 
and  muscular  suture  and  skin  sutures.  All  went  well  with  Mrs. 
N.  subsequently,  the  icterus  let  up,  the  itching  of  the  skin  dis- 
appeared, the  temperature  did  not  exceed  in  the  evening  38.1°. 
On  the  change  of  dressings  on  the  tenth  day  the  wound  was 
healed  per  primam,  the  sutures  were  removed.  Except  for 
pretty  frequent  colored,  thin  stools,  which  depend  upon  the  pro- 
fuse discharge  of  bile  into  the  intestine,  is  the  condition  of  the 
patient  excellent,  until  quite  unexpectedly  on  the  19.  4.  98  after- 
noon, about  half-past  two,  a  stool  mixed  with  blood  occurred. 
The  pulse  is  good.  Mrs.  N.  is  given  tannalbin  and  opium,  and 
the  advice  to  lie  absolutely  quiet.  On  the  19.  4.  evening  the 
pulse  is  very  small,  temperature  36.5°,  bloody  stools  very  fre- 
quent, involuntary.     Patient  gets  red  wine,  camphor,  tannalbin 


2^6  GALLSTONE  DLSEASE. 

and  opium.  On  the  20.  4.  great  weakness,  pulse  scarcely  to  be 
felt,  striking  pallor,  continued  bloody  stools.  Therefore  20.  4. 
early  i  ^  Hters  salt  solution  subcutaneously.  The  condition 
improves  somewhat,  but  becomes  worse  again  in  the  course  of 
the  day,  in  spite  of  the  employment  of  restoratives  and  opium, 
so  that  in  the  evening  an  infusion  of  salt  solution  again  became 
necessary.  Mrs.  N.  had  to  the  21.4.  a  trying  night;  the  bloody 
stools  did  not  cease.  21.4.  early  the  patient  looked  very  pale. 
Pulse  136,  temperature  37.6°,  consequently  salt  water  infusion 
and  opium.  Mrs.  N.  sinks  more  and  more  under  frequent  dis- 
charges of  stinking  blood  ;  on  the  22.  4.  early  morning  she 
bleeds  severely  from  the  puncture  after  infusion  of  salt  solution. 
Therefore  one  desists  from  further  therapeutic  endeavors.  Death 
ensues  at  midnight.     Autopsy  not  made. 

A  very  difficult  case  for  diagnosis  is  the  following,  in  which 
there  was  a  c/wonic  obstruction  frojii  stone,  and  at  the  same  time 
a  cancer  of  the  pajicreas. 

G.  G.,  58  years,  station-master,  from  Vienenburg.  Entered,  1 1. 
6.  98.  Operation,  15.  6.  98.  Choledochotomy.  Drainage  of 
the  hepaticus.  Discharged,  4.  7.  98.  (Died  morning,  at  4 
o'clock.) 

Amnesis. — Parents  dead  (were  healthy) ;  patient  had  three 
brothers  and  sisters,  of  whom  two  live  and  are  healthy.  He  has 
one  daughter  who  is  healthy.  Patient  otherwise  healthy  ;  has 
twice  had  gastric  fever  (1869,  1872),  suffered  frequently  from 
intestinal  catarrh.  He  had  never  had  trouble  with  the  stomach 
until  suddenly  1-2  years  ago,  about  midday,  without  any  previ- 
ous error  in  diet,  a  severe  cramp-like  pain  occurred  in  the  pit  of 
the  stomach  ;  no  vomiting  ;  duration  a  few  hours  ;  no  jaundice 
followed.  Then  again  complete  good  feeling.  On  the  1 1.  April 
in  afternoon,  after  already  for  two  days  an  unbearable  feeling 
after  dinner  had  preceded,  which  lasted  several  hours,  a  cramp 
occurred  in  the  pit  of  the  stomach  without  vomiting.  In  the 
night  following  jaundice,  which  did  not  again  disappear.  Since 
then  the  appetite   has   remained  poor  up  till  entrance  into  the 


CLINICAL  AND  OPERATION  HISTORIES.  2/7 

clinic  here.  After  that  the  cramp,  which  was  exceedingly  vio- 
lent, had  passed  after  5-6  hours,  good  health  returned  again  ; 
the  stools  remained  some  three  weeks  clay-colored,  the  urine 
persistently  beer-brown.  Four  weeks  after  the  first  attack  a 
second,  approximately  as  severe,  accompanied  by  vomiting ; 
again  for  some  days  colorless  stools.  On  medical  advice  a  diet 
was  followed  in  which  all  fat  was  excluded.  Afterwards  two 
light  attacks  of  short  duration.  The  jaundice  and  icteric  urine 
persisted,  but  the  stools  were  colored  (also  after  the  slight 
attacks).  At  the  present  a  couple  of  times  chills  (temperature 
not  taken).  The  bodily  weight  has  up  till  now  (that  is  inside  of 
seven  weeks)  lost  33  pounds.  Dr.  Piltz  of  Vienenburg  ad- 
vised operation. 

Status  Praesens. — Large,  spare  man  ;  condition  of  organs 
normal,  intensely  icteric  (itching  of  skin),  urine  free  from  sugar 
and  albumin  contains  bile  pigment.  Gall-bladder  not  to  be  felt 
as  a  tumor,  marked  sensitiveness  to  pressure  under  the  right  ribs. 
Liver  but  little  enlarged. 

Diagnosis. — Stone  in  the  choledochus,  carcinoma  not  to  be 
absolutely  excluded. 

Operation. — Chloroform  anaesthesia.  i  ^  hours.  Longitu- 
dinal incision  in  the  right  rectus  abdominal  muscle,  extending 
below  the  navel.  Very  small,  contracted  gall-bladder.  Adhe- 
sions of  the  stomach  and  omentum  with  the  under  surface  of 
the  liver,  as  well  as  the  region  of  the  cystic  duct.  After  separa- 
tion of  the  adhesions  the  choledochus,  which  is  dilated  to  the 
size  of  the  little  finger,  is  easily  found,  and  in  it  after  some 
searching  a  concretion  is  detected.  After  fixation  of  this  with 
the  finger  an  incision  is  made  upon  the  stone  with  much  hemor- 
rhage. In  doing  this  the  stone  slips  into  the  retroduodenal 
part  of  the  duct,  and  cannot  be  pressed  out.  Immediately  clear 
bile  escapes.  With  forceps  and  much  difficulty  a  good  many 
fragments  of  a  soft  stone  were  removed  ;  others  remained  be- 
hind. Drainage  of  the  hepaticus  and  likewise  the  lower  part  of 
the  choledochus   through  the  long  incision,  tamponade  around 


2^8  GALLSTONE  DISEASE. 

the  drainage  tubes.  Closure  of  the  abdominal  wound  in  the 
upper  and  lower  parts  by  through  and  through  interrupted 
sutures  and  some  skin  sutures.  Immediate  escape  of  bile.  On 
the  day  of  operation  the  evening  temperature  was  37.5°,  to  then 
rise  on  the  16.  6.  to  38.4°  and  on  the  17.  6.  to  38.1°  evening, 
since  it  was  under  38°.  The  dressings  were  soaked  on  the  20. 
6.,  and  were  consequently  changed.  The  stools  remained  color- 
less, the  urine  is  clearer.  On  the  22.  6.  again  change  of  dress- 
ings, the  tubes  were  removed,  and  from  the  choledochus  (intes- 
tinal part)  fragments  were  removed  by  washing.  Mr.  G.  on  the 
following  days  is  very  weak  ;  despite  the  flow  of  bile,  the  patient 
remains  icteric,  the  urine  contains  more  bile  pigment,  the  stools, 
which  can  only  with  difficulty  be  attained  by  purgatives,  are 
colorless.  From  the  24th  on  the  dressings  must  be  daily 
changed,  since  so  much  bile  escaped.  The  patient  cannot 
retain  his  food,  he  vomits  frequently  ;  even  the  smallest  quan- 
tity of  milk  causes  vomiting.  On  the  26.  6.,  on  this  account,  a 
catheter  is  for  the  first  time  introduced  through  the  choledochus 
into  the  duodenum  and  milk  and  egg  injected  through  it  into 
the  duodenum.  The  stools  remain  colorless.  The  nourishment 
through  the  choledochus  was  repeated  again  on  the  29.  6.,  and 
still  again  twice  on  the  30.  6.  Mr.  G.  vomits  this  day  after  the 
injection  of  milk,  which  the  first  time  was  given  with  castor  oil. 
The  stools  are  colorless  and  the  urine  contains  bile  pigment. 
The  strength  fails  more  and  more,  and  we  desist  from  the 
attempts  to  nourish  through  the  choledochus.  The  last  dress- 
ing occurred  on  2.  7.  From  the  hepaticus  there  escapes  on 
outwashing  muddy  bile.  The  temperature  does  not  rise.  On 
the  4.  7.  morning,  at  4  o'clock,  Mr.  G.  died  of  exhaustion,  in 
consequence  of  the  entire  failure  of  nourishment,  since  at  every 
endeavor  to  give  him  nourishment  Mr.  G.  responds  by  vomiting  ; 
nutrient  enemata  he  did  not  retain. 

Necropsy  discloses  multiple  abscesses  in  the  liver,  perihepatic 
suppuration,  sclerosis  of  the  pancreas,  especially  in  the  head, 
kinking  of  the  duodenum.  A  piece  of  the  pancreas  was  ex- 
cised ;  the  microscopic  examination  discloses  "scirrhus." 


CLINICAL  AND  OPERATION  HISTORIES.  279 

The  complication  of  lithogenotis  obstruction  of  tJie  cholcdocJius 
ivitJi  a  carcinoma  of  the  papilla  of  the  dModenuni  was  met  in  the 
following  case  : 

G.  K.,  60  years,  merchant,  from  Rodenkirchen  i.  Oldenburg. 
Entered,  16.  11.  97.  Open,  18.  11.  97.  Cystectomy.  Chole- 
dochotomy  with  suture  (stone)  ;  later,  hepaticus  drainage.  Dis- 
charged, 29.  II.  97.      Carcinoma.      Dead. 

Amnesis. — Parents  dead  (father  of  old  age,  mother  of  phthisis); 
of  brothers  and  sisters,  a  sister  is  living  in  good  health.  The 
patient  suffered  in  his  youth  from  malaria,  a  disease  which  was 
epidemic  in  East  Friesland,  otherwise  the  patient  was  healthy. 
At  the  age  of  20  years  he  removed  to  Oldenburg,  and  there  had 
several  inflammations  of  the  lungs.  In  the  year  1887  he  sud- 
denly had  colic-like  pains  which  lasted  about  19  days.  The 
appetite  failed,  sleep  left  the  patient.  After  this  attack  the 
patient  was  a  single  day  yellow,  then  treatment  with  Carlsbad 
water  improved  the  condition  so  that  he  was  again  healthy  for 
about  ^  year.  Eight  years,  except  for  pains  in  the  stomach, 
which  occurred  entirely  at  the  beginning,  he  was  thoroughly 
well,  and  attained  again  his  former  bodily  weight  (over  180 
pounds  from  145  pounds).  In  1896,  in  the  middle  of  May, 
there  occurred  a  new  attack  of  colic  with  immediate  jaundice. 
This  condition  lasted  3  weeks.  Vomiting  did  not  occur.  The 
patient  went  to  Carlsbad  from  the  middle  of  July  to  the  middle 
of  August ;  there  existed  only  very  slight  jaundice,  which  did 
not  disappear.  On  the  whole,  Carlsbad  was  without  success. 
Occasionally  pains  in  the  stomach  occurred.  A  new  attack  of 
colic  with  jaundice  occurred  at  Christmas,  1896  (a  week  dura- 
tion.). Subsequently  now  and  then  pains  in  the  stomach  ;  the 
appetite  was  bad,  whilst  previously  it  had  been  good.  The 
patient  was  the  middle  of  May,  1897,  four  weeks  in  Neuenahr, 
but  not  under  treatment.  However,  the  patient  felt  better. 
Until  the  middle  of  August,  1897,  it  went  well  with  him,  then 
an  attack  of  colic  with  jaundice  (8  days).  Now  there  occurred 
a  condition  under  which,  without  being  severely  ill,  the  patient 


280  GALLSTONE  DISEASE. 

had  much  to  suffer  from  itching  at  night  in  consequence  of  jaun- 
dice. In  November  pains  in  the  stomach  were  occasionally  felt, 
associated  with  chills.  In  consequence  of  the  advice  of  Dr. 
Kreyenborg  the  patient  came  hither. 

Status  Prsesens. — 174  cm.  tall;  spare  man,  of  about  130 
pounds  weight ;  only  traces  of  jaundice.  Urine  is  not  now  so  clear 
as  formerly  (declaration  of  patient).  The  examination  of  the  urine 
discloses  neither  albumin,  sugar,  nor  bile  pigment  (16.  11.  after- 
noon). Heart  and  lungs  normal  (slight  emphysema).  Palpation 
gives  no  results. 

Diagnosis  of  stone  in  the  choledochus  is  made  ;  by  reason  of 
the  age  of  the  patient  one  thinks  of  carcinoma. 

Operation. — Chloroform  anaesthesia,  i  ^  hours.  On  open- 
ing the  belly  by  a  longitudinal  incision  one  comes  upon  ex- 
tensive adhesions  of  the  liver  to  omentum,  intestine  and  abdomi- 
nal wall.  The  gall-bladder  is  not  visible  and  first  appears  after 
separation  of  extensive  adhesions.  It  shows  a  diverticulum  in  its 
fundus.  After  exposure  of  the  choledochus  one  feels  in  it  a 
pigeon-egg-sized  stone.  The  gall-bladder  tears,  clear  bile  es- 
capes. The  gall-bladder  is  extirpated,  the  cystic  artery  sepa- 
rately ligated.  Upon  the  stump  of  the  cystic  duct  and  liver  bed 
a  gauze  tampon  ;  the  incision  in  the  choledochus,  through  which 
the  stone  can  easily  be  extracted,  was  closed  with  7  sutures,  the 
abdominal  wound  closed  by  peritoneal  and  muscle-fascia  and 
skin  suture  up  to  the  place  of  exit  of  the  gauze — the  upper  part 
of  the  wound  by  silk  sutures.  In  the  beginning  course  good, 
pulse  strong  and  full,  then  occurred  a  flow  of  bile  which  weak- 
ened the  patient  very  much.  The  pulse  becomes  more  frequent 
and  small.  On  the  28.  i  i.  97,  under  anaesthesia,  the  suture  of 
the  choledochus  was  completely  removed  and  the  hepatic  duct 
drained  with  a  tube.  Patient  is  brought  pulseless  from  the 
operating  table.  Death  ensued  on  the  29.  11.  97  at  11  o'clock 
in  the  evening,  after  profuse  vomiting  of  blood  had  previously 
taken  place  several  times. 

Necropsy  disclosed  carcinoma  of  the  duodenum  in  the  neigh- 


CTJNICAT.  AND  OPERATION  IITSTORTES.  28  I 

borhood  of  the  papilla  and  carcinomatous  glands  on  the  chole- 
dochus. 

TJic  complication  of  chronic  obstruction  of  the  clioledocJuis  by 
stone  witJi  tumor  of  the  pancreas^  probabh'  of  inflammatory  nature, 
was  observed  in  the  following  case  : 

Mr.  Christ.  G.,  53  years,  employing  baker,  from  Blankenburg 
a.  H.  Entered,  17.  i.  99.  Operation,  18.  1.99.  Choledochot- 
omy,  choledocho-duodenostomy.    Discharged,  26.  2.  99.    Cured. 

Amnesis.  —  Family  history  without  importance.  Patient  was 
always  healthy  until,  entirely  without  premonition,  at  Christmas, 
1897,  he  had  an  attack  of  cramps  in  the  stomach  of  2-3  hours 
duration,  and  attended  by  vomiting.  These  attacks  recurred 
until  April,  1898,  4-5  times.  Once  in  February  (?)  there  was 
jaundice  with  it.  In  the  summer  of  1898  excellent  health.  At 
the  end  of  October  or  the  beginning  of  November,  return  of  the 
attacks.  The  middle  or  end  of  November  jaundice  appeared, 
which  has  since  remained  uninterruptedly,  although  with  vary- 
ing intensity,  and  was  especially  disagreeable  because  of  the 
itching  of  the  skin.  The  stools  were  at  times  entirely  grey,  then 
again  colored,  yet  never  normally  dark.  The  urine  was  beer- 
brown.  The  appetite,  otherwise  good,  was  after  the  attacks 
bad  for  days.  The  emaciation  amounted  to  about  20  pounds  in 
all. 

Status  Prsesens. — Medium-sized,  spare,  somewhat  weakl}% 
very  icteric  man.  Organs  normal.  Urine  free  from  albumin  and 
sugar,  rich  in  bile  pigment.  Liver  not  enlarged.  Gall-bladder 
not  to  be  palpated.     Sensitiveness  to  pressure  in  its  region. 

Diagnosis. — Lithogenous  obstruction  of  the  choledochus, 
malignant  tumor  almost  certainly  to  be  excluded. 

Operation,  18.  i.  99.  Longitudinal  incision  in  the  right  rectus 
muscle.  Gall-bladder  small,  adherent  to  omentum.  Liver  en- 
larged. Separation  of  adhesions  after  ligature.  Cystic  duct 
empty.  Supra-duodenal  part  of  the  choledochus  is  well  exposed. 
In  it  a  hazlenut-sized  stone.  Easy  removal  after  a  2  cm.  long 
incision.  Head  of  pancreas  \^er}^  hard.  After  separation  of  the 
24 


282  GALLSTONE  DISEASE. 

omentum  major  and  minus  the  head  of  the  pancreas  was  freely 
exposed.  Probably  it  is  an  inflammatory  induration  (sclerosis  of 
age),  possibly  a  carcinoma.  The  incision  in  the  choledochus 
was  not  sutured,  but  employed  for  an  anastomosis  between  the 
duodenum  and  the  choledochus.  Choledocho-duodenostom)'. 
Tampon  of  suture.  Partial  closure  of  the  abdominal  wound  b\' 
through  and  through  silk  sutures.  A  two  hour  difficult  opera- 
tion.     Good  chloroform  anaesthesia. 

Course  very  good  and  afebrile.  Icterus  disappears.  On  dis- 
charge the  patient  has  excellent  good  health. 

The  lithogenoiis  obstriiction  of  the  clioledoclius  is  complicated 
with  s  trie  1 1  ire  of  the  eJioleeioeJiiis  and  eirrJiosis  of  the  liver  in  the 
following  case  : 

Mrs.  G.,  31  years,  wife  of  a  merchant,  from  Odessa.  En- 
tered, 9.  2.  97.  Operation,  11.  2.97.  Choledochotomy,  chole- 
cystenterostomy.  Discharged,  17.  3.  97.  12.  2.  98  explora- 
tory incision  (bihary  cirrhosis).      Died. 

Patient  is  said  to  have  always  been  healthy  until  6  years  ago. 
About  this  time  pains  in  the  stomach  occurred  independently  of 
food.  The  original  pains  in  the  stomach  increased  to  colic. 
Especially  violent  attacks  occurred  two  years  ago  and  then  in 
the  years  1896  and  1897;  their  duration  was  extremely  variable, 
varying  from  y,  hour  to  2  days.  Vomiting  never  present, 
patient  is  said  to  have  been  jaundiced  for  5  years  alread}'.  The 
stools  were  white,  only  from  time  to  time  streaked  with  brown  ; 
the  urine  beer-brown,  never  yellow.  During  the  attacks  the 
jaundice  increased,  but  otherwise  also  persisted.  Violent  itch- 
ing of  the  skin,  constipation.  In  the  year  1895,  therefore,  the 
patient  sought  the  springs  of  Carlsbad  ;  this  brought  improve- 
ment, but  no  cure.  Since  as  related  already,  in  the  years  1896 
and  1897  again  violent  colics  occurred,  the  patient  decided  upon 
operation. 

Status  Prsesens. — Large,  thin  woman.  Intense  icterus. 
Heart  and  lungs  normal.  The  lower  border  of  the  liver  extends 
three  finger-breadths  beyond  the  curve  of  the  ribs  ;  upwards  the 


CLINICAL  AND  OPERATION  HISTORIES.  283 

liver  dullness  is  not  enlarged.  The  gall-bladder  is  not  to  be 
felt ;  in  its  region  and  in  the  pit  of  the  stomach  marked  sensi  - 
tiveness  to  pressure.  No  splenic  tumor.  The  urine  is  beer- 
brown  in  color,  contains  bile  pigment,  but  no  albumin  or  sugar. 
White  stools.      No  fever.      Pulse  j6,  regular  and  strong. 

Diagnosis. — Obstruction    of   the    choledochus,    probably    of 
lithogenous  character. 

Operation  on  the  11.  2.  97.  Morphine-atropine-chloroform 
ancHesthesia.  Longitudinal  incision  in  the  right  rectus  abdominal 
muscle.  On  opening  the  belly  the  enlarged  liver  appears  ;  its 
appearance  is  healthy.  On  its  under  surface  is  the  normal- 
sized  gall-bladder,  which  is  free  from  stones.  Between  it,  the 
pylorus  and  the  omentum  adhesions,  which  are  difficult  to  free. 
On  palpating  the  deep  bile  ducts  one  feels  in  the  ductus  chole- 
dochus a  pigeon-egg-sized  stone,  which  is  removed  by  incision. 
Now  sounding  of  the  choledochus  above  and  below.  Above 
the  passage  is  free,  below  the  duct  is  strictured  ;  it  is  impossible 
to  push  the  sound  towards  the  papilla  of  the  duodenum.  There- 
fore it  was  concluded  to  do  a  cholecystenterostomy,  after  that 
the  wound  in  the  choledochus  was  closed  by  four  sutures.  From 
the  incised  gall-bladder  muddy  bile  escapes.  At  the  side  oppo- 
site the  mesentery  the  duodenum  is  opened  by  a  longitudinal 
incision,  thereupon  follows  the  suture  of  the  posterior  serous 
surfaces  of  the  gall-bladder  and  intestine  ;  a  suture  of  the  mucosa 
was  not  done  because  of  the  fear  of  incrustation  of  the  sutures  ; 
then  suture  of  the  anterior  serous  surfaces.  Complete  closure 
of  the  abdominal  wound  by  suture.  Dressing.  Duration  of 
the  operation,  2^^  hours. 

The  subsequent  course  favorable.  Patient  was  continuously 
free  from  fever.  On  the  second  day  after  the  administration  of 
glycerine  passage  of  flatus.  After  ten  days  renewal  of  dress- 
ings. Stitches  removed.  Abdominal  wound  healed  without 
reaction.  The  urine  clears  up,  the  stools  became  light  brown. 
The  icterus  pales,  the  itching  of  the  skin  diminishes  more  and 
more.  On  the  17.  3.  the  patient  was  discharged  from  the  clinic. 
Only  traces  of  jaundice  were  still  present. 


284  GALLSTONE  DLSEASE. 

Since  subsequently  the  icterus  again  became  more  marked, 
and  the  patient  failed  very  much,  she  again  seeks,  at  the  advice 
of  her  physician,  the  clinic.  We  cannot  convince  ourselves  by 
the  examination  that  a  second  operation  would  attain  any  sort  of 
relief,  since  the  jaundice  could  depend  upon  no  mechanical 
obstruction  of  the  choledochus,  but  rather  upon  a  grave  altera- 
tion of  the  liver-cells  by  chronic  biliary  congestion  (biliary  cirrho- 
sis). On  the  entreaty  of  the  perplexed  patient,  who  saw  in  an 
operation  her  only  hope,  an  exploratory  laparotomy  was  done 
on  the  12.  2,  98.  There  were  numerous  adhesions,  the  gall- 
bladder-intestinal fistula  worked  with  apparent  perfection,  in  the 
choledochus  no  stones  were  to  be  detected  ;  the  liver  showed 
the  picture  of  biliary  cirrhosis.  Death  eight  hours  after  the 
operation  in  collapse  (chloroform  ?).      No  autopsy  permitted. 

Upon  a  choledochus  stone  sticking  in  a  carcinoniatons  stricture 
I  chanced  in  the  following  case  : 

Mrs.  C.  M.,  59  years,  wife  of  a  merchant,  from  Magdeburg. 
Entered,  27.  i.  98.  Oper.,  29.  i.  98.  Choledocho-duodenostomy. 
Cystectomy  (carcinoma).  Discharged,  11.  2.  98,  half-past  eight 
o'clock  in  the  evening.      Dead. 

Amnesis. — Parents  dead,  three  brothers  and  sisters  are  living 
and  in  good  health.  Patient  was  always  healthy,  married  at  24 
years,  mother  of  six  healthy  children,  one  dead.  Seventeen 
years  ago  had  a  pleurisy,  always  had  a  sound  stomach.  Never 
jaundice.  In  the  beginning  of  November  patient  noticed  weight 
in  the  pit  of  the  stomach,  radiating  pains  in  the  sacrum  ;  with 
this  condition  all  foods  were  well  borne.  On  account  of  this 
distress  a  treatment  for  tape-worm  was  instituted,  and  a  tape- 
worm actually  passed  (2.  12.).  Immediately  jaundice  occurred, 
vomiting,  loss  of  appetite,  persistent  sacral,  side  and  abdominal 
pains.  Never  fever.  The  stools  were  always  colorless,  the 
urine  dark.  The  treatment  consisted  of  hot  poultices  and  the 
prescription  of  light  diet,  at  times  morphine.  The  condition 
continued  in  the  same  manner,  that  is  there  was  continual  pain. 
Within  three  days  the  pains  are  less.  The  patient  tolerates  only 
fluid  nourishment,  and  is  emaciated. 


CLINICAL  AND  OPERATION  HISTORIES.  285 

Status  Praesens. — Medium-sized,  thin  woman,  everywhere 
yellow  (running  into  green).  Urine  rich  in  bile  pigment,  with- 
out albumin  and  sugar.  Liver  enlarged  (three  fingers  below  the 
ribs),  gall-bladder  not  to  be  felt. 

The  diagnosis  made  is  chronic  choledochus  obstruction  fi-om 
stone  ;  a  new  growth  is  not  with  positiveness  to  be  excluded. 

Operation. — Chloroform  anaesthesia.  Duration  of  the  opera- 
tion, I  3^  hours  ;  good  anaesthesia;  at  the  conclusion  pulse  small 
and  irregular.  Typical  longitudinal  incision,  very  little  pannicu- 
lus  adiposus.  The  gall-bladder  without  stones,  not  enlarged, 
contains  mucus  (obliteration  of  the  cystic  duct  ?).  One  feels 
somewhat  to  the  left  of  it  a  hardness,  which  is  taken  for  a  stone. 
The  choledochus  extensively  adherent  to  the  intestine,  is  by 
reason  of  large  veins  with  difficulty  accessible  ;  the  veins  were 
double  ligatured  and  cut.  Incision  of  the  choledochus  ;  there 
escapes  little  clear  bile.  Toward  the  intestine  the  sound  strikes 
upon  a  marked  stricture,  before  which  a  large  stone  is  lodged  ; 
the  stone  is  extracted,  the  stricture  is  hardl}^  to  be  passed  by  a 
fine  probe.  The  stricture  is  regarded  as  cancerous,  likewise 
hard  glands  are  to  be  felt  in  the  neighborhood.  On  account  of 
this  choledochoenterostomy,  which  is  on  account  of  the  great 
depth  very  difficult.  To  render  it  easier  extirpation  of  the  gall- 
bladder. Tampon  down  to  the  obliterated  cystic  duct  stump 
and  suture.  Closure  of  the  abdominal  wound  as  far  as  the  upper 
angle  by  interrupted  silk  sutures. 

Course  febrile.  On  change  of  dressings  on  the  8.  2.  98  it  is 
apparent  that  the  sutures  have  held  completely.  There  develops 
the  picture  of  diffuse  purulent  cholangitis.  Patient  is  still 
markedly  jaundiced.  Urine  still  colored  by  bile  pigment.  Mrs. 
M.  must  be  frequently  dressed  subsequently  on  account  of  the 
marked  secretion  from  the  wound  ;  the  fever  is  high  (over  39°  C). 
The  pulse  is  continuously  very  frequent  and  small.  The  loss  of 
strength  increases  until  the  patient  on  the  11.  2.  98  is  released  from 
her  suffering.  Necropsy  not  allowed.  An  anastomosis  between 
gall-ducts  and  the  intestine  is  to  be  resorted  to  as  seldom  as  possi- 
ble, since  it  can  give  rise  to  a  cholangitis  of  purulent  character. 


286  GALLSTONE  DISEASE. 

An  extensive  carcinoma  existed  in  the  followinfj  case  ;  on  ac- 
count  of  the  feebleness  of  the  patient  only  an  exploratory  incision 
was  made  : 

Mrs.  J.  St.,  65  years,  wife  of  a  landowner,  from  Borry  (Kreis 
Hameln).  Entered,  8.  11.  98.  Oper.,  12.  11.  98.  Laparotomia 
exploratoria  (carcinoma).  Discharged,  17.  11.  98.  Dead  of 
uraemia. 

Amnesis. — Parents  are  dead,  a  sister  is  living  and  healthy. 
Mrs.  St.  married  at  25  years  old  and  always  enjoyed  good 
health,  except  for  hemorrhoidal  trouble  ;  she  is  the  mother  of 
six  children,  of  whom  four  still  live  and  are  healthy.  Since 
some  fifteen  weeks  ago  dates  the  present  disease  of  the  patient. 
She  has  had  poor  health,  the  appetite  became  poorer,  the  stools 
were  usually  constipated,  sometimes  also  diarrhoeal  ;  at  the  same 
time  emaciation  in  a  remarkable  degree  appeared.  At  times 
pains  occurred,  which  in  part  consisted  of  pressure,  in  part  of 
twists  in  the  upper  abdominal  region  and  of  burning  in  the 
stomach.  For  7  weeks  jaundice  has  existed,  of  which  the  inten- 
sity has  increased  steadily.  With  severer  pains  the  jaundice 
began.  The  stools  were  always  colorless  and  the  urine  dark. 
The  pains  like  those  occurring  earlier  occasionally  abated,  to  in- 
crease at  night.  The  appetite  was  very  poor,  vomiting  was  wanting ; 
the  emaciation  was  striking,  in  all  it  was  estimated  at  30  pounds. 
Fever  is  said  never  to  have  appeared.  The  treatment  consisted 
in  warm  applications  to  the  abdomen,  regulation  of  the  diet,  so 
that  fat  was  avoided,  and  the  drinking  of  Carlsbad  Miihlbrunnen. 
The  attending  physician.  Dr.  Mittmann,  made  the  diagnosis  of 
gall-stone  disease,  and  finally  advised  consultation  of  me. 

Status  Prsesens. — Medium-sized,  feeble,  very  thin,  markedly 
icteric  woman.  Except  for  the  changes  due  to  age  in  the  vas- 
cular system  and  lungs  which  are  to  be  expected,  the  examina- 
tion of  the  organs  afford  nothing  particular,  save  that  the  liver  is 
very  much  enlarged,  especially  in  the  right  lobe,  which  extends 
3-4  finger-breadths  below  the  navel  ;  the  gall-bladder  is  not  to 
be  palpated.      The  liver  feels  quite  smooth,  and  is  not  sensitive. 


CLINICAL  AND  OPERATION  HISTORIES.  28/ 

The  urine  is  very  rich  in  bile  pigment,  without  containing  albu- 
min or  sugar.  Glands  are  not  to  be  felt,  especially  the  supra- 
clavicular.     No  splenic  tumor. 

Diagnosis. — Carcinoma  choledochi,  perhaps  associated  with 
stones.  The  relatives  under  all  the  circumstances  wished  an 
operation,  so  that  nothing  would  remain  undone.  The  patient 
also  did  not  wish  to  leave  the  chnic  without  operation. 

Operation. — Chloroform  anaesthesia.  Typical  longitudinal 
incision  in  the  right  rectus  abdominal  muscle.  Subcutaneous 
cellular  tissue  almost  gone,  all  tissues  yellow-stained,  careful 
control  of  bleeding.  Liver  shows  itself  icteric,  beginning  cirr- 
hosis. Nodules  on  the  posterior  surface,  in  the  choledochus 
apparently  a  stone  imbedded  in  carcinomatous  tissue.  In  con- 
sideration of  the  impossibility  of  removing  the  new  growth, 
closure  of  the  abdominal  wound.  Duration  of  the  operation, 
fifteen  minutes. 

The  diagnosis  was  confirmed  ;  for  a  carcinoma  spoke  :  i .  The 
cachexia  (gall-stone  patients  may,  indeed,  often  also  be  suffer- 
ing as  the  cancer  patients,  but  they  are,  however,  the  excep- 
tions) ;  2.  the  absence  of  colics  ;  3.  the  very  intense  icterus 
which  constantly  increased  ;  4.  the  persistently  colorless  stools 
(in  choledochus  stone  frequent  variation  in  the  color  and  inten- 
sity of  the  icterus  ;  5.  the  absence  of  splenic  tumor  (with  chole- 
dochus stone  splenic  tumor  very  frequent). 

The  course  was  afebrile.  On  the  14.  and  15.  11.  complete 
anuria.  Whence  ?  No  fever,  belly  soft,  flatus  passes  spontane- 
ously. Died  on  the  17.  11.  of  uraemia.  No  post-mortem  pos- 
sible. 

I  had  in  this  case  to  the  relatives  refused  the  operation  as 
useless,  but  I  regarded  it  as  cruel  to  the  patient,  who  saw  in  an 
operation  her  only  hope  of  cure,  not  to  grant  her  wish  for  an 
operation.  An  exploratory  operation  often  has  so  great  an 
influence  on  the  mind  of  a  patient  that  one  cannot  always  carry 
out  his  principle  of  refraining  from  every  operation  in  inoperable 
carcinomata. 


2SS  GALLSTONE  DISEASE. 

13- 

Inflammatory  or  Lithogenous  Icterus? 

We  ma\-  assume  ^?//  iiiflainniatoi-y  icterus  in  the  following 
case  : 

]\I.  Sell.,  2^  years,  wife  of  a  firemaker,  from  Cothen.  En- 
tered, 4.  10.  98.  Operation,  13.  10.  98.  Cystostomy.  Dis- 
charged, cured,  8.  11.  98. 

Amnesis —  Patient,  the  mother  of  three  healthy  children,  has 
never  been  actually  really  ill  until  the  present  sickness.  About 
2  years  ago  she  became  ill  with  cramp-like  pains  in  the  region 
of  the  stomach,  which  radiated  toward  the  back,  were  attended 
b}-  \omiting  and  recurred  in  3-4  week  intervals.  Attacks  of 
this  kind  lasted  12-24  hours,  and  left  behind  a  feeling  of  great 
depression  and  weakness.  Jaundice,  discoloration  of  stools, 
deep  coloration  of  urine  are  said  never  to  have  occurred.  On 
the  26.  9.  98  she  suddenly  was  again  taken  with  cramps  in  the 
stomach,  and  profuse  bilious  vomiting,  complete  loss  of  appetite 
and  moderate  fever.  Three  days  later  jaundice  clearly  appeared, 
the  urine  is  said  since  then  to  be  colored  yellow  brown,  the  pa- 
tient had  not  observed  the  stools.  There  remained  existing  dull 
pains  and  exquisite  sensitiveness  to  pressure  in  the  region  of  the 
gall-bladder.  In  the  evening  an  elevation  of  temperature  oc- 
curred, the  jaundice  increased. 

Status  Praesens. — Powerfully -built,  well-nourished  woman, 
with  pronounced,  intense  jaundice  and  38.5°  evening  tempera- 
ture. Gall-bladder  region  exquisitely  sensitive  to  pressure, 
tumor  not  to  be  detected  there.  Liver  not  enlarged.  Upper 
abdominal  region  slightly  distended  and  upon  pressure  painful. 
Urine  contains  bile  pigment  in  abundance,  no  albumin,  no  sugar. 
Stools  colorless. 

Diagnosis  inclines  bet\\-een  cholecystitis  with  attendant  jaun- 
dice and  acute  obstruction  of  the  choledochus. 

Therefore  we  at  first  abstain  from  operation  ;  treatment  con- 
sists of  rest  in  bed,  and  administration  of  castor  oil. 


CLINICAL  AND  OPERATION  HISTORIES.  289 

.\fter  several  large  stools  the  pains  quickly  abated,  likewise 
the  sensitiveness  to  pressure  in  the  region  of  the  gall-bladder 
and  the  distension  in  the  upper  part  of  the  abdomen.  Only  the 
appetite  remains  always  poor.  9.  10.  always  yet  jaundice,  in 
urine  bile  pigment,  stools  light  ;  appetite  bad,  no  fever.  Since 
the  condition  does  not  change,  the  woman  presses  for  a  decision, 
whether  operation  or  not.  and  stones  in  carefully  examined  stools 
are  not  found  ;  operation  was  decided  upon  and  on  the  13.  10. 
98  performed. 

Operation. — T\-pical  longitudinal  incision  in  the  right  rectus 
abdominal  muscle  to  3  cm.  beneath  the  level  of  the  navel.  On 
opening  the  belly  the  gall-bladder  presents  itself  extensively  ad- 
herent to  omentum  and  stomach.  The  adhesions  were  sepa- 
rated in  part  bluntly  and  in  part  by  cutting  and  the  ducts  pal- 
pated. Stones  are  not  to  be  felt  in  the  choledochus,  also  not  in 
the  retro-duodenal  part  of  it.  The  pancreas  is  not  enlarged. 
The  jaundice  must  also,  since  the  cysticus  was  free  from  stones 
and  such  only  were  in  the  gall-bladder,  be  interpreted  as  inflam- 
matory jaundice.  The  proper  method  was  here  without  question 
the  cystostomy.  This  was  done  in  the  usual  manner.  For  fixa- 
tion of  the  gall-bladder  to  the  parietal  peritoneum  catgut  was  in 
part  used.  In  the  gall-bladder  were  found  about  20  pea-sized 
crumbling  soft  cholesterin  stones  with  clear  bile.  Good  course. 
Jaundice  diminishes.  The  flow  of  bile  varies  within  normal 
limits.      Discharged  on  8.  2.  with  closed  fistula. 

Remarks. — Patients  with  acute  gallstone  disease  and  jaun- 
dice are,  if  at  all  possible,  not  to  be  operated  upon.  The  in- 
flammatory jaundice,  of  which  the  explanation  is  very  easy,  is 
in  practice  not  to  be  realized,  since  we  cannot  diagnosticate  it. 
If  we  operate  and  it  abates,  then  despite  this  we  may  have  had 
to  do  with  a  direct  or  indirect  lithogenous  icterus  (pressure  from 
a  stone  in  the  neck  of  the  gall-bladder  upon  the  choledochus). 
Small  stones  in  the  choledochus  escape  palpation,  and  they  often 
first  appear  months  after  in  the  stools  or  are  dissolved  in  the  in- 
testine.    All  of  this  makes  the  recognition  of  an  inflammatory 


290  GALLSTONE  DISEASE. 

icterus  impossible  ;  that  it  exists  is  very  obvious  to  us,  but  no 
one  can  prove  it. 

Frequently  one  assumes  eni  inflanunatory  jaundiee  and  by  the 
operation  determines  that  the  ease  is  one  of  litJwgenous  jau7idice. 

Mrs.  F.  R.,  40  years,  wife  of  a  court  servant,  from  Tangermiinde 
a.  E.  Entered,  26.  i.  99.  Operation,  27.  i.  99.  Cystectomy, 
Drainage  of  the  hepaticus,  hepatopexy.  Discharged,  19.  3.  99. 
Cured. 

Amnesis. — Family  history  unimportant.  Mrs.  R.,  according 
to  her  statements,  in  early  youth  was  already  always  much 
plagued  with  diseases  ;  since  her  confirmation  she  has  suffered 
from  pains  in  the  stomach  which  are  said  to  have  been  cramp- 
like, dependent  upon  catching  cold  and  severe  labor,  and  were 
of  short  duration.  Patient  married  at  3 1  years  old,  mother  of 
two  children  which  are  dead,  one  abortion.  Pains  in  the 
stomach  became  with  time  more  frequent  and  violent.  After  her 
marriage  her  stomach  improved,  and  then  again  became  worse. 
In  the  summer  of  1898,  in  the  evening  after  eating,  a  pain  in  the 
stomach  occurred  the  violence  of  which  was  exceedingly  great. 
Since  October,  1898,  the  appetite  has  been  very  poor.  With 
the  menstruation  the  distress  increases.  In  November,  1898, 
jaundice  occurred  after  a  cramp  in  the  stomach.  Carlsbad  salts 
improved  the  jaundice.  After  Christmas  Mrs.  R.  was  better  ; 
about  a  week  the  appetite  was  moderate.  On  the  19th  of  this 
month,  in  the  evening,  a  violent  attack  of  pain,  which  began  in 
the  region  of  the  stomach,  but  then  more  particularly  had  its 
seat  in  the  lumbar  region  ;  Mrs.  R.  vomited,  afterwards  improve- 
ment. Toward  morning  a  new  attack  which  lasted  until  after- 
noon. A  new  attack  since  22.  i.  until  it  became  very  severe  on 
the  24.  I,  On  the  25.  i.  jaundice  was  observed.  To-day  (26.  i.) 
only  sensitiveness  to  pressure  in  the  region  of  the  stomach,  no 
spontaneous  pains.  Stools  are  yellow,  lighter  than  normal,  the 
urine  was  early  to-day  brown. 

Status  Prsesens. —  Heart,  lungs,  etc.,  normal.  In  the  region 
of  the  gall-bladder  a  round,  very  painful,  tumor  (26.  i.  99). 
After  castor  oil  it  is  on  the  following  day  smaller  and  less  sensi- 


CLINICAL  AND  OPERATION  HISTORIES. 


291 


tivc.  Liver  somewhat  enlarged.  Slight  jaundice  (light-yellow 
color  of  the  sclerae).      Bile  pigment  in  urine. 

Diagnosis. — Acute  cholecystitis.  Perhaps  stones  in  the 
choledochus.     Jaundice  probably  of  inflammatory  nature  (?). 

Operation.— Chloroform  anaesthesia.  Longitudinal  incision 
in  the  right  rectus  abdominal  muscle.  Liver  movable.  Gall- 
bladder enlarged  by  inflammation,  which,  however,  is  again  in 
retrogression.  Aspiration  of  the  contents  of  the  gall-bladder  ; 
slimy  muddy  bile.  Incision  of  the  gall-bladder,  tamponade  of 
it.  Exposure  of  the  gall-bladder  adherent  to  the  stomach  as  far 
as  the  cysticus.  In  the  choledochus  a  concretion  is  detected, 
therefore  incision  after  a  futile  attempt  to  press  the  stone  into  the 
gall-bladder.  Involuntary  choledocholithotripsy,  removal  of 
fragments.  Extraction  of  a  small  stone  from  the  gall-bladder. 
Removal  of  the  gall-bladder  after  separation  from  the  liver.  An 
attempt  to  sound  the  choledochus  from  the  cysticus  fails.  Sepa- 
rate ligation  of  the  cysticus  and  cystic  artery.  Partial  suture  of 
the  choledochus.  Drainage  of  the  hepaticus  by  a  tube  the 
diameter  of  a  finger.  Hepatopexy  with  6  catgut  sutures.  Tam- 
ponade. Closure  of  the  abdominal  wound  with  Spencer  Wells' 
sutures.      Dressing.      Duration,  2^  hours. 

Course  very  good.  Drainage  works  admirably.  On  the 
I  oth  day  removal  of  the  tube.  Then  daily  change  of  dressings 
and  outwashing  of  the  hepaticus,  whereby  constantly  yet  some 
concretions  come  to  light.  Icterus  quickly  gone.  Appetite 
good ;  from  the  1 5th  day  on  little  bile  escapes  outwardly. 
Choledochus  fistula  closes  quickly.      On  the  19.  3.  discharged. 

The  stones  in  the  gall-bladder  and  cysticus  were  as  small  as 
grape  seed,  the  stone  in  the  choledochus  as  large  as  a  nut.  This 
stone  already  a  long  time  had  its  seat  in  the  choledochus,  which 
was  very  much  dilated  (thumb-sized)  and  had  thin  walls.  It  had 
lain  in  the  choledochus  without  symptoms  :  the  latency  of  stones 
in  the  choledochus  may  not  occur  so  frequently  as  in  the  gall- 
bladder, but  it  is  surely  more  frequent  than  one  imagines.  The 
acute  cholecystitis,  which  existed,  extended  to  the  choledochus 
and  put  into  motion  the  stone  there  which  had  been  months  or 


292  GALLSTONE  DISEASE. 

longer  quiescent.  The  drainage  of  the  hepaticus  I  had  pre- 
ferred to  the  suture  which  was  attempted,  since  bile  would  con- 
tinually press  through,  and  from  the  hepaticus  clearly  escaped 
muddy  bile.  The  opening  of  the  cysticus  was  moreover  pretty 
low  down  in  the  choledochus,  so  that  the  site  of  incision  in  the 
choledochus  lay  to  the  liver  side  of  the  cystic  duct.  The  duct 
was  very  narrow.  Of  a  removal  of  the  stones  out  through  the 
gall-bladder  after  Rose  there  could  be  no  thought. 

A  case,  in  wliicJi  a  lit] loge nous  icterus  existed  12  years  long 
almost  witJwut  remission,  zuas  the  following.  The  patient  with  a 
large  stone  in  the  choledochus  was  cured  by  operation  : 

Mrs.  E.  G.,  49  years,  wife  of  an  agriculturist,  from  Veltheim 
a.  O.  Entered,  20.  i.  98.  Operation,  22.  i.  98.  Choledochot- 
omy  and  ectomy.     Discharged,  21.  2.  98.      Cured. 

Father  of  the  patient  died  of  old  age,  mother  is  living  in  health 
at  70  years  of  age.  Patient  had  already,  as  a  girl  about  20 
years  of  age,  cramps  in  the  stomach,  but  no  vomiting  with  them  : 
married  at  22  years  of  age,  mother  of  9  children.  The  fre- 
quency of  the  attacks  steadily  increased.  Patient  could  not 
bear  all  things  ;  for  example,  pulse,  fat  and  sour  foods.  She 
suffered  a  great  deal  from  constipation  and  eructations.  First 
jaundice  in  1885  after  an  attack  of  cramps,  since  about  one  year 
jaundice  after  the  frequently  recurring  colics,  of  which  the  dura- 
tion was  up  to  3  days.  Since  about  15  years  ago  the  patient 
has  always  been  icteric,  the  intensity  of  the  color  varied,  with  it 
marked  itching  of  the  skin  ;  cramp  attacks  afterwards  as  before, 
increasing  in  painfulness.  After  these  the  stools  were  regularly 
white,  otherwise  somewhat  brown-colored,  the  urine  was  always 
brown.  Recently  the  patient  has  lived  on  milk  and  eggs.  Since 
about  1893  the  yellow  color,  especially  on  the  anterior  abdomi- 
nal wall  and  the  back  of  the  hands,  had  passed  into  brown.  For 
two  years  the  patient  at  times  vomits  after  eating,  rather  mouth- 
fuls  than  under  the  action  of  abdominal  pressure.  In  the  even- 
ing she  frequently  has  fever  and  chills. 

Status  Praesens. — Medium-sized,  thin  woman.  The  entire 
skin  colored   dirty  yellow,   sclerae,   and   mucous   membranes   of 


CLINICAL  AND  OPERATION  HISTORIES. 


^93 


mouth  yellow  ;  bronze-colored  are  the  anterior  abdominal  wall 
and  the  skin  of  the  dorsum  of  the  forearm  and  hand.  The  liver 
is  enlarged,  palpable,  and  extends  almost  to  the  navel.  Urine 
dark-brown,  contains  neither  albumin  nor  sugar,  very  considera- 
ble bile  pigment.      Pulse  before  operation,  80.      No  fever. 

Diagnosis. — Chronic  lithogenous  obstruction  of  the  chole- 
dochus  (papilla  ?). 

Operation. — Chloroform  anaesthesia,  i  hour.  Longitudinal 
incision  in  the  right  rectus  abdominal  muscle.  The  small  gall- 
bladder adherent  to  the  stomach,  separation  of  adhesions,  in  so 
doing  opening  of  the  gall-bladder  from  which  clear  bile  escapes. 
No  stone  in  the  gall-bladder.  The  choledochus  and  hepaticus 
dilated  to  the  size  of  a  finger.  No  stone  to  be  felt.  Behind  the 
duodenum  a  suspicious  hardness.  Opening  of  the  supraduo- 
denal part  of  the  choledochus,  much  muddy  bile.  The  sound 
strikes  at  6  cm.  toward  the  intestine  a  hazelnut-sized  stone. 
Removal  by  bimanual  procedure  ;  from  the  hepaticus  also  a 
somewhat  smaller  stone  is  removed.  Choledochus  suture  with 
7  silk  sutures.  All  ducts,  including  the  cysticus,  were  easily 
sounded.  Excision  of  the  gall-bladder.  Overcasting  of  the 
stump,  careful  ligature,  firm  tamponade,  suture  of  the  abdomi- 
nal wound  above  and  below,  in  the  middle  the  gauze  tampon 
brought  out.      In  the  wall  of  the  gall-bladder  a  stone. 

The  course  is  admirably  smooth,  the  evening  temperature 
keeps  under  38°  C.  The  skin  becomes  lighter,  the  urine  free  from 
bile  pigment.  On  discharge  on  the  21.  2.  Mrs.  G.  is  abso- 
lutely free  from  all  distress,  her  skin  is  still  pigmented,  but 
markedly  less  than  at  her  reception.      No  hernia. 


14. 

Stomach  or   Gall-Bladder  or  Both  Affected. 

Very  frequently  gall  trouble  is  ascribed  by  physician  and  patient 
to  the  stomach,  and  at  the  same  time  the  case  is  07ie  of  gallstones 
alone.      I  quote  the  following  cases  : 


294  GALLSTONE  DISEASE. 

Mr.    L.,    35     years,     tinman,    from    Quedlinburg.      Entered, 
12.6.97.      Oper.,    14.   6.   97.      Cystostomy    and    cystocotomy.  ! 
Discharged,  15.  7.  97.    Cured  (26.  7.  97). 

Patient,  the  father  of  2  children,  is  said  to  have  always  beeni 
healthy  until  5  years  ago.  About  this  time  he  was  attacked  !ji 
with  violent  attacks  of  pain  arising  in  the  region  of  the  gall- 
bladder, and  radiatincr  from  it  toward  the  back  and  the  rio-ht 
axilla.  These  attacks  occurred  occasionally,  in  the  first  years 
about  every  4  months  ;  in  the  two  last  years  they  recurred 
about  every  6  weeks.  Icterus  and  vomiting  were  never  present, 
the  stools  always  constipated.  The  patient  suffered  extraordi- 
narily in  body  and  mind,  he  lost  his  zeal  for  labor  and  became 
steadily  weaker.      For  a  week  again  violent  pains. 

Status  Prsesens. — Powerfully-built,  large  man.  No  icterus, 
heart  and  lungs  normal.  In  the  region  of  the  gall-bladder  an 
indefinite,  very  painful  resistance  to  be  felt.  At  the  examination 
on  the  second  day  after  his  entrance  the  resistance  and  the  pain 
are  no  longer  demonstrable.  Patient  has  been  well  purged, 
and  to  this  the  improvement  is  indeed  to  be  ascribed.  Li\'er 
and  spleen  not  enlarged.  Urine  contains  nothing  abnormal. 
Stools  of  brown  color.  Temperature  in  evening  in  rectum, 
38.3°.      Pulse  regular,  strong,  74  beats  in  the  minute. 

Diagnosis. — Acute  cholecystitis. 

Operation  on  the  14.  6.  97.  Chloroform  anaesthesia.  Lon- 
gitudinal incision  in  the  right  rectus  abdominal  muscle.  On 
opening  the  belly  the  omentum  is  seen  adherent  to  the  under 
surface  of  the  gall-bladder ;  the  latter  is  completely  covered  by 
the  liver,  tensely  filled,  but  not  really  enlarged.  Moreover, 
bands  extend  from  the  gall-bladder  to  the  stomach.  All  adhe- 
sions were  separated.  After  that  the  gall-bladder  has  been 
freed,  one  feels  in  it  large  stones.  The  puncture  of  the  gall- 
bladder discloses  purulent  bile.  The  puncture  is  enlarged,  the 
gall-bladder  dried  with  gauze,  and  now  3  hazelnut-sized  stones 
extracted.  In  the  cysticus  a  hazelnut-sized  fixed  stone,  on  this 
account  cystocotomy.  5  sutures.  Duration  of  operation,  i  3^ 
hours. 


CLINICAL  AND  OPERATION  HISTORIES.  295 

Course  of  the  wound  completely  normal  ;  no  fever.  Bile 
escaped  for  a  week  after  operation.  Operation  wound  well 
healed.  On  the  14th  day  the  patient  left  his  bed;  now  very 
profuse  flow  of  bile,  so  that  L.  had  to  be  dressed  every  2d  day. 
Gradually  the  bile  diminished,  so  that  the  patient  could  be  dis- 
charged on  the  15.  7.  97,  with  a  scarcely  secreting  biliary  fistula. 
On  the  28th  of  July  the  patient  again  presents  himself  and 
states  that  the  fistula  has  been  closed  two  days. 

Remarks. — The  patient  works  again  in  a  factory,  and  cannot 
praise  enough  the  success  of  the  operation.  In  his  home  no 
one  had  thought  of  gallstones,  but  he  was  always  treated  for 
stomach  trouble. 

TJie  diagnosis  was  based  iipoii  the  previojis  history  and  the  ex- 
cessive tenderness  of  the  reghn  of  the  gall-bladder.  How  often 
in  such  cases  no  examination  is  made,  since  one  regards  the 
stomach  as  the  criminal.  /  With  exact  palpation  one  ought  to 
find  the  painful  resistj^rtg^^nder  the  right  rectus  abdominal 
muscle. 

77ie  abatement  of  tkejpains  on  purgation  was  observed  even  in 
tins  case.  That  pits  had  already  collected  in  the  gall-bladder  came 
as  a  surprise  to  nie.  \j  X 

The  following  case  was  Treated  a  long  time  for  nicer  of  the 
stomach,  although  I  personally  do  not  doubt  that  there  were  only 
gallstones. 

Mrs.  M.  L.,  29  yrs.,  wife^a  captain,  from  Halberstadt.  En- 
tered, 14.  9.  98.  Oper.,  I  5j^9.  98.  Cystostomy.  Discharged, 
12.  10.  98. 

Amnesis. — Patient  luis*4iad  all  the  children's  diseases,  other- 
wise never  really  ill.  >J^ou!>and  one-half  years  ago  she  fell  ill  4 
days  after  a  confinement  witift  occasionally  occurring  violent  cramp- 
like pains  in  the  region  of  the  liver,  which  radiated  toward  the  back 
and  the  shoulder-blades  ;  with  these  occurred  vomiting.  These 
attacks  recurred  almost  every  day  for  8  weeks.  The  attending 
physician  diagnosticated  cramps  of  the  stomach.  Later  the 
attacks  occurred  only  every  3  or  4  weeks.      Some  eight  months 


296  GALLSTONE  DLSEASE. 

after  the  first  attack  the  diagnosis  of  ulcer  of  the  stomach  was 
made,  and  four  weeks'  treatment  for  ulcer  of  the  stomach  fol- 
lowed ;  in  addition  to  this  still  a  Carlsbad  cure  at  home.  Despite 
it  the  patient  had  to  still  endure  several  violent  attacks  ;  with 
them  icterus  was  never  present ;  the  stools  were  always  natural 
colored.  For  two  years  the  patient  has  been  completely  free 
from  attacks,  but  on  the  other  hand  has  to  suffer  constantly  from 
a  pressing  pain  in  the  region  of  the  gall-bladder,  which  at  times 
was  so  severe  that  she  could  not  bend,  and  could  by  no  means 
execute  any  brisk  bodily  movement  (tennis  play  and  the  like). 
She  suffered  constantly  from  headache,  great  weakness  and  dis- 
comfort. 

The  attending  physician  would  send  the  patient  absolutely  to 
Carlsbad.  "  One  ought  not  immediately  chose  the  worst, 
operation." 

Status  Prsesens. — Very  strong  and  well-nourished  woman. 
With  deep  palpation,  slight  sensitiveness  to  pressure  in  the  re- 
gion of  the  gall-bladder.  Gall-bladder  not  palpable,  liver  not 
enlarged.  No  icterus.  Stools  of  regular  form  and  color.  Belly 
everywhere  soft,  not  distended.  Heart  and  lungs  normal.  Pulse 
80,  strong  and  regular.  No  fever.  Urine  free  from  albumin, 
sugar  and  bile  pigment. 

Diagnosis. — Gallstones  in  the  gall-bladder. 

Operation. — Quiet  chloroform  anaesthesia.  Longitudinal  in- 
cision in  the  right  rectus  abdominal  muscle  from  curvature  of 
ribs  downwards.  No  adhesions.  Gall-bladder  not  actually  en- 
larged and  pathological.  In  the  gall-bladder  and  cysticus 
numerous  stones  to  be  felt.  Puncture  of  the  gall-bladder, 
evacuation  of  about  20  ccm.  of  dark-brown  bile.  Enlargement 
of  the  puncture  by  incision.  Extraction  of  65  gallstones,  of 
which  some  10-12  were  seated  deep  in  the  cysticus.  The 
stones,  pea  to  cherrystone  size,  light -yellow,  angular.  Suture 
of  the  gall-bladder  to  the  parietal  peritoneum.  Drainage  with 
tube.  Partial  closure  of  the  abdominal  wound  by  layer  suture. 
Immediate  escape  of  bile.      16.  9.  98.    Severe  cramp-like  pains, 


CLINICAL  AND  OPERATION  HISTORIES.  297 

which  arc  alleged  to  radiate  from  the  wound  to  the  back,  and 
occasionally  occur.  Last  evening  morphine  for  this.  These 
attacks  recur  ;  there  appears  moderate  icterus.  Larger  flow  of 
bile.  Positively  a  small  stone  has  been  during  the  operation 
pressed  out  of  the  cystic  duct  into  the  choledochus.  It  is  prob- 
ably so  small  that  it  can  pass  the  papilla.  On  the  21.9.  still 
moderate  icterus.  Good  appetite  and  stool.  27.  9.  98.  The 
icterus  passes  very  rapidly.  The  flow  of  bile  remains  steadily 
profuse  ;  bowels  move  only  with  castor  oil  or  injections  ;  appetite 
and  general  condition  good. 

Tube  removed.     With  the  sound  no  stone  can  be  detected. 

I.  10.  98.  Patient  up.  Heretofore  no  stones  found  in  the 
stools.  3.  10.  98.  For  3  days  the  patient  has  had  poor  appe- 
tite, and  from  time  to  time  complains  of  sacral  pains.  No  more 
icterus.  Profuse  flow  of  bile.  Yesterday  evening  great  discom- 
fort ;  towards  ten  o'clock  exceedingly  violent  pains  in  the 
sacrum,  which  radiate  to  the  right  shoulder  ;  on  this  account 
morphine  subcutaneously.  Thereupon  improvement.  This  morn- 
ing again  severe  pains,  complete  loss  of  appetite,  bilious  vomit- 
ing, then  the  pains  abate  somewhat ;  there  remains  a  great  gen- 
eral depression.  Since  there  is  a  suspicion  founded  upon  the 
distress  that  still  there  is  a  stone  in  the  choledochus,  the  fistula 
of  the  gall-bladder  is  plugged  as  tightly  as  possible  by  a  wooden 
plug  wrapped  with  gauze,  in  order  to  drive  the  stone  through 
the  choledochus  into  the  intestine.  Immediately  after  the 
closure  of  the  fistula  severe  pains  in  the  stomach  and  sacrum. 
In  stools  no  stone.  Plstula  on  the  12.  10.  almost  closed.  No 
pains.      Slight  escape  of  bile.      (Dressing  every  3  days.) 

Remarks. — Had  all  the  stones  got  under  motion,  and  had 
they  sought  to  pass  the  cysticus  and  the  choledochus,  then  the 
patient  would  have  had  from  her  65  stones  an  incredible  amount 
of  suffering.  The  inflammation  of  the  gall-bladder  was  so  mini- 
mal that  one  is  obliged  to  assume  that  the  continuous  distress, 
which  consisted  by  no  means  of  colics,  but  only  of  pains  in  the 
stomach,  is  explained  by  the  irritation  of  the  stones  already 
25 


298  GALLSTONE  DISEASE. 

lying  in  the  cystic  duct.  Where  are  the  dangers  here  in  an 
operation  ?  In  fact  they  are  less  than  an  expectant  treatment. 
It  is  to  be  assumed  that  during  the  operation  a  small  stone  has 
been  pressed  out  of  the  cysticus  into  the  choledochus  ;  it  Avill 
surely  from  this  duct  get  into  the  intestine,  so  that  a  complete 
cure  will  result.  According  to  the  latest  news  the  patient  feels 
extraordinarily  well  and  has  not  again  had  pain,  so  that  it  is  to 
be  assumed  that  the  small  stone  has  passed  the  papilla  of  the 
duodenum. 

However,  the  case  teaches  that  one  in  palpating  the  gall- 
bladder must  guard  himself  from  pressing  stones  into  the 
choledochus.  On  this  account  I  apply  there,  where  it  is  possible, 
before  the  palpation  and  the  squeezing  of  the  gall-bladder,  a 
slightly  compressing  clamp  on  the  cysticus,  so  as  to  prevent  the 
passage  of  a  concretion  into  the  choledochus. 

In  the  following  case  the  decision  ivhethcr  there  was  mi  ulcer 
of  the  stomach  or  cholelithiasis  zvas  very  cii-fficiilt  : 

A.  E.,  44  years,  wife  of  a  carpenter,  from  Halberstadt.  En- 
tered, 23.  2.  98.  Operation,  28.  2.  98.  Cystectomy.  Dis- 
charged, 10.  5.  98. 

Patient  declares  that  already  as  a  child  she  frequently  had 
pains  in  the  stomach,  later  she  had  also  eructations  without  vomit- 
mg.  She  bore  all  foods.  Five  or  six  weeks  ago  she  observed 
a  feeling  of  fullness  in  the  stomach  ;  usually  after  eating  the 
pain  occurred,  two  weeks  ago  colic-like  pains,  vomiting  and  loss 
of  appetite.      Patient  is  said  never  to  have  had  jaundice. 

Status  Prsesens. — Pretty  large,  extremely  obese  woman. 
Nothing  particular  in  the  organs.  A  dilated  stomach  is  not 
demonstrable,  likewise  atony  ;  hydrochloric  acid  normal  ;  on  the 
other  hand  there  exists  a  resistance  in  the  region  of  the  gall- 
bladder, a  tumor  is  not  to  be  felt.  Most  sensitive  place  to 
pressure  the  pit  of  the  stomach.  Whether  the  case  is  one  of 
ulcer  of  the  stomach  or  gallstones  is  not  certain. 

Operation.— Chloroform    anaesthesia    (bad).       Duration,    i^ 
hours.      Duration  of  operation,  i  i^  hours.     On  account  of  the 


CLINICAL  AND  OPERATION  HISTORIES.  299 

very  abundant  panniculus  and  the  possibility  of  a  stomach  affec- 
tion an  extensive  incision  in  the  median  line  from  ensiform  pro- 
cess to  the  navel.  Since  this  does  not  give  sufficient  room,  a 
transverse  incision  is  made  perpendicular  to  the  first  toward  the 
right  as  far  as  the  lateral  border  of  the  rectus.  Nevertheless 
the  procedure  is  difficult  enough.  With  difficulty  one  succeeds 
in  reaching  the  gall-bladder,  since  enlightenment  and  advance  is 
hindered  by  extensive  adhesions,  which  on  the  one  side  unite 
the  anterior  surface  of  the  liver  with  the  abdominal  wall  and  on 
the  other  the  stomach  and  colon  with  the  gall-bladder,  and  also 
the  cysticus.  The  liver  is  not  enlarged,  the  gall-bladder  does 
not  extend  with  its  fundus  beyond  the  liver  border.  It  is  much 
thickened,  one  cannot  feel  stones  from  the  outside.  After  sepa- 
ration of  the  adhesions,  one  proceeds  to  separate  the  gall-bladder 
from  the  hver  for  the  purpose  of  excision  ;  it  does  not  succeed 
without  profuse  bleeding.  The  cystic  duct  is  ligated  so  that  a 
piece  of  it  remains.  Overcasting  of  the  stump  with  3  sutures. 
Through  and  through  suture  of  the  long  incision,  the  transverse 
incision  remains  unsutured  ;  out  of  it  are  brousrht  2  loner  eauze 
strips  which  tampon  the  liver  bed  and  the  cysticus  stump.  The 
gall-bladder  contains  muddy,  somewhat  purulent,  fluid,  its  walls 
are  very  much  thickened,  especially  at  the  fundus,  fibrino-puru- 
lent  deposit  in  separate  places  of  the  ulcerous  degenerated 
mucous  membrane.  One  small  mulberry  stone.  The  case  illus- 
trates the  difficulties  of  making  a  correct  diagnosis.  The  small 
gall-bladder  lay  far  above  the  lower  border  of  the  liver.  The 
colics  were  not  very  pronounced  ;  only  of  constant  pain  in  the 
stomach  after  eating  (even  after  liquid  diet)  did  the  strong  and 
obese  patient  complain,  in  whom  one  saw  nothing  of  the  severe 
changes  in  the  gall-bladder.  In  another  hospital  she  had  been 
a  week,  without  that  the  chief  physician  could  decide  upon  an 
operation,  because  objective  data  were  wanting.  Ulcer,  inflam- 
matory processes  in  the  gall-bladder,  hysteria  were  considered. 
Who  should  fathom  it  ?  Only  the  exploratory  incision  could 
give  a  solution.     The  operation  in  2  stages — an  immediate  suture 


300 


GALLSTONE  DISEASE. 


by  the  abdominal  wall  was  on  account  of  the  deep  situation  of 
the  gall-bladder  impossible — would  have  stumbled  upon  great 
difficulties  with  the  obesity  of  the  patient.      The  extirpation  w^as 
also  not  easy. 

The  temperature  is  on  the  evening  of  the  day  of  operation 
37.8°,  the  same  the  following  evening.  On  the  2.  3.  98  it 
reached,  however,  39.3°.  The  pulse  reached  142  beats  a 
minute,  flatus  does  not  pass,  the  abdomen  is  distended.  One 
begins  in  the  fear  that  there  develops  a  septic  peritonitis  on  the  ^.  t,. 
98,  since  the  morning  temperature  amounts  to  38°,  the  pulse, 
however,  is  very  small  and  shows  i  50  beats,  with  infusions  of 
physiological  salt  solution  each  day,  morning  and  evening,  each 
about  Ij4  liters;  in  all  14  infusions  were  made.  On  3.  3.  98, 
evening,  temperature  36.9°,  pulse  uncountable. 


4- 

38.6 

39-0 

9- 

38.1 

38.5 

5- 

38.4 

38.6 

10. 

38.1 

38.8 

6. 

37-6 

38-5 

1 1. 

37-5 

38.5 

7- 

38.0 

3^-7 

12. 

37-5 

38.3 

8. 

377 

38.5 

13- 

37-4 

37-6 

Since  then  normal.  The  condition  improves  slowly,  stools 
follow,  in  fact  diarrhoea  temporarily  occurs,  the  pulse  becomes 
gradually  slower  and  increases  in  tension.  On  the  first  change  of 
dressings  on  the  S.  ^.  the  median  incision  had  for  the  most  part 
separated,  the  stomach  lay  in  front  adherent  all  around,  from  the 
transverse  wound  pus  escapes  after  the  removal  of  stinking  gauze. 
Afterwards  frequent  change  of  dressings,  until  10.  5.  98,  still  13 
times.  The  median  wound  is  well  cicatrized,  the  transverse 
wound  to  a  small  granulating  spot.  Mrs.  E.  comes  yet  for 
dressing.      Good  health. 

When  the  pulse  was  so  markedly  accelerated  (up  to  140)  and 
fever  occurred  we  thought  positively  of  a  peritonitis,  and  the 
woman  also  actually  gave  this  impression.  The  vomiting  was 
as  in    peritonitis  ("overflow  of  stomach   contents"),  so  that  we 


CLINICAL  AND  OPERATION  HISTORIES.  3OI 

Still  believe  the  salt  infusions  have  had  a  real  value.  With 
diffuse  purulent  peritonitis  after  appendicitis  we  have  obtained 
very  good  results  with  this  "  washing  of  the  blood." 

In  the  following  cases  the  cholelithiasis  zvas  complicated  with 
affections  of  the  stomach  : 

(a)  Ch.  G.,  44  years,  wife  of  a  carrier,  from  Elbingerode  a.  H. 
Entered,  19.  2.  99.  Operation,  20.  2.  99.  Ectomy.  Pyloro- 
plasty.     Discharged  cured,  25.  3.  99. 

Amnesis. — Family  history  of  no  importance.  Mrs.  G.  has 
on  the  whole  been  healthy.  As  a  child  of  3  years  had  nervous 
fever;  married  at  21  years  of  age,  mother  of  9  children  of  which 
2  are  dead.  With  the  fourth  child,  14  years  ago,  the  patient 
had  articular  rheumatism,  which  lasted  quite  2  years.  For  2  years 
the  patient  has  suffered  from  pains  which  began  in  the  left  lower 
part  of  the  abdomen,  mounting  to  the  navel  and  then  going 
around  the  left  side  into  the  sacrum.  To  this  was  added  head- 
ache and  dizziness,  finally  fainting.  Sometimes  mucus  and  bile 
were  vomited.  At  first  these  attacks  occurred  at  long  intervals 
—  y^  year — now  very  frequently.  The  appetite  is  said  to  have 
been  poor  for  2  years.  The  violent  pain  lasted  with  the  attacks 
some  hours,  the  entire  duration  is  said  to  have  amounted  to  as 
much  as  8  weeks,  and  the  patient  was  so  long  confined  to  bed. 
Jaundice  was  never  present.  The  stools  were  regular.  Mrs. 
G.  is  said  to  be  emaciated,  especially  recently. 

Status  Prsesens. — Medium-sized,  somewhat  weakly,  pale 
woman.  Organs,  save  the  heart,  normal.  Systolic  murmur  at 
the  apex  (mitral  insufficiency).  Liver  not  enlarged.  Region  of 
the  gall-bladder  resistant  and  sensitive  to  pressure.  Dilatation 
of  the  stomach.  Urine  free  from  pathological  constituents. 
Right-sided  small,  irreducible  femoral  hernia. 

Diagnosis. — Gallstones  in  the  gall-bladder.  Cysticus  patient. 
Adhesions.  Peripyloritis.  Femoral  hernia  on  right  side.  On 
account  of  vitium  cordis  morphine-ether  anaesthesia. 

Operation  on  20.  2.  99.  Longitudinal  incision  in  the  right 
rectus   abdominal   muscle.      Gall-bladder    tensely   dilated,    liver 


302  GALLSTONE  DISEASE. 

very  large,  bluish-red  (Congestion  ?).  No  adhesions.  In  the 
cysticLis  several  small  stones.  Walls  of  the  gall-bladder  mark- 
edly thickened,  the  bile  somewhat  muddy  is  caught  under  all 
aseptic  precautions  for  examination  as  to  bacteria.  Gall-bladder 
is  extirpated.  Lively  bleeding.  Pylorus  ventriculi  hypertro- 
phied,  marked  dilatation.  Pyloroplastic.  Gastroenterostomy  is 
not  performed,  smce  the  patient  is  pretty  cyanotic.  Radical 
operation  and  excision  of  a  very  thickened  fatty  right-sided 
femoral  hernia  through  a  small  incision.  Tampon  of  the  liver 
bed  and  stump  of  the  cysticus.  Suture  of  the  abdominal  walls. 
Operation,  i  y^  hours.  Good  course.  No  fever  or  vomiting. 
Cured. 

Remarks. — Although  here  there  were  no  adhesions  present, 
yet  the  w^alls  of  the  gall-bladder  impressed  one  as  inflamed. 
It  was  however  slight  and  depended  upon  an  insignificant  infec- 
tion. If  one  wishes  to  believe  in  the  spastic  or  mechanical  na- 
ture of  the  colics  in  this  case,  I  also  have  nothing  to  say 
against  it ;  in  view  of  the  continuous  and  violent  colics  the 
operation  was  indicated  upon  social  grounds.  In  the  bile  the 
bacterium  coli  was  demonstrated. 

(b)  Mrs.  St.,  wife  of  a  director,  from  Oppeln.  Entered,  17. 
I.  99.  Operation,  18.  i.  99.  Ectomy,  gastroenterostomy  after 
von  Hacker.      Discharged,  22.  2.  99. 

Amnesis. — Parents  of  the  patient  are  living  and  in  good 
health.  Patient  as  a  young  girl  suffered  very  much  from  her 
stomach  (once  in  the  passages  there  was  blood)  ;  this  distress 
she  lost  after  marriage.  Since  about  4  years  cramp-like  pains  in 
the  region  of  the  gall-bladder.  These  attacks  occurred  sud- 
denly at  night  and  lasted  about  iX  hour,  leaving  behind  nausea 
and  eructations.  The  last  attack  was  in  November,  1898.  The 
appetite  in  general  was  good,  save  at  the  time  of  the  attacks. 
Errors  in  diet  easily  excited  attacks.  Emaciation  did  not  occur. 
Traces  of  jaundice  are  said  to  have  been  observed  in  the  spring. 

Status  Prsesens. — No  enlargement  of  the  liver,  no  jaundice. 
Region  of  the  gall-bladder  somewhat  sensitive.      Clear  succus- 


CLINICAL  AND  OPERATION  HISTORIES.  303 

sion  sound  over  the  stomach.  Urine  free  from  abnormal  con- 
stituents. Motor  functions  of  the  stomach  delayed.  Hyper- 
acidity. 

Diagnosis. — Soft  stone-containing  gall-bladder,  atonia  ven- 
triculi  (ulcus  ventriculi).  Adhesions  between  gall-bladder  and 
pylorus. 

Operation,  18.  i.  99.  Longitudinal  incision  in  the  right 
rectus  abdominal  muscle.  Gall-bladder  large,  filled  with  stones 
and  bile,  broadly  adherent  to  the  duodenum.  Cysticus  free. 
Ectomy.  Since  the  stomach  is  very  large,  gastroenterostomy 
after  von  Hacker.  i  y^  hour  operation.  Good  chloroform  an- 
aesthesia. Smooth  afebrile  course.  Patient  has  vomited  a  few 
times.      Then  quick  recovery.      Discharged  well. 

(c)  S.  G.,  33  years,  wife  of  a  butcher,  from  Strobepk.  En- 
tered, 31.  10.  98.  Oper.,  2.  II.  98.  Cystectomy,  gastroenter- 
ostomy.     Discharged,  9.  12.  98.      Cured. 

Amnesis. — Parents  are  still  living,  mother  is  healthy,  the 
father  suffers  with  his  stomach  ;  of  8  brothers  and  sisters,  2 
suffer  with  their  stomachs.  Patient  entirely  healthy,  married  at 
22  years  old  and  is  the  mother  of  3  healthy  children.  For  3 
years  Mrs.  G.  has  been  ill  ;  she  declares  she  suffers  from  colics  ; 
suddenly  there  occurs  vomiting,  diarrhoea,  loss  of  appetite  lasting 
usually  a  day.  For  2  years  there  has  been  also,  according  to 
her  statement,  constant  pains  in  the  back  and  lower  part  of  the 
abdomen.  Almost  2  years  ago  Dr.  Weidling  of  Halberstadt 
diagnosticated  uterine  flexion.  Operation  did  not  relieve  the 
distress.  Since  the  spring  of  1898  the  pain  has  been  more  in 
the  pit  of  the  stomach.  Medicine  was  without  result.  Patient 
suffered  from  offensive  eructations.  In  the  morning  vomiting 
succeeded  cramp-like  pains  in  the  right  lower  abdominal  region 
which  radiated  to  the  stomach  and  sacrum.  Later  the  seat  of 
pain  was  more  in  the  upper  right  abdominal  region  and  then  they 
occurred  in  the  stomach.  The  internal  treatment  achieved  no 
success.  At  the  suggestion  of  Dr.  Gravinghoff  Mrs.  G.  came  into 
the  clinic. 


304  GALLSTONE  DISEASE. 

Status  Prsesens. — Medium  -  sized,  strong,  well  -  nourished 
woman.  Organs  normal,  urine  free  from  albumin,  sugar  and 
bile  pigment.  Liver  is  not  enlarged,  gall-bladder  not  now  to  be 
palpated,  pain  on  pressure  only  occasionally  upon  deep  pressure. 
Stomach  slightly  enlarged,  slight  enteroptosis  ;  to  the  right  of 
the  median  line  under  the  curve  of  the  ribs  there  is  to  be  felt  an 
almost  fist-sized  tumor  extensively  movable  over  the  median  line 
toward  the  left.  Motor  functions  of  the  stomach  delayed,  chemi- 
cal almost  normal.      Slight  hyperacidity. 

Diagnosis. — Stones  in  the  gall-bladder,  to  the  median  side 
immovable  tumor,  probably  arising  from  the  pylorus  (carcinoma 
or  ulcus  ventriculi). 

Operation. — Longitudinal  incision  in  the  right  rectus  abdom- 
inalis  muscle  from  the  curve  of  the  ribs  downward  about  I  5  cm. 
long.  On  opening  the  abdomen  the  previously  felt  immovable 
tumor  is  seen  to  be  the  very  much  thickened,  inflamed  and  hyper- 
trophied  pylorus.  In  the  mesocolon  transversum  toward  the 
flexura  hepatica  a  fluctuating  spot  is  seen,  which  impresses  one 
as  a  softened  lymph-gland.  Exploratory  puncture  discloses  no 
pus.  Gall-bladder,  large  and  thickened,  is  filled  with  numerous 
concretions.  In  the  lig.  hepatico  gastricum  glands  are  to  be 
felt,  and  since  it  would  have  been  impossible  to  remove  them,  and 
there  was  also  the  danger  that  we  had  to  do  with  cancer,  only  a 
gastroenterostomy  after  von  Hacker  with  suture  was  made, 
after  that  a  transverse  incision  8  cm.  long  towards  the  left  above 
the  navel  had  given  the  necessary  access.  The  gall-bladder, 
which  was  in  spots  adherent,  was  freed,  and  after  clamping  of  the 
cysticus  to  prevent  stones  slipping  into  the  choledochus,  was  ex- 
tirpated. Double  ligature  of  the  cysticus  with  strong  catgut. 
The  free  bleeding  from  the  liver  bed  was  checked  by  a  tampon 
of  sterile  gauze,  the  transverse  wound  entirely  closed  and  the 
longitudinal  wound  in  its  lower  part  by  through  and  through  in- 
terrupted silk  sutures  and  some  skin  sutures,  whilst  the  gauze 
was  brought  out  of  the  upper  part  of  the  wound.  Duration  of 
the  operation,  i  y^  hours.    Good  chloroform  anaesthesia.    Smooth 


CLINICAL  AND  OPERATION  HISTORIES.  305 

afebrile  course.      The  patient  was  discharged  on  the  9.  12.  98  in 
really  better  condition. 

Whether  there  was  a  cancer  of  the  pylorus  or — what  is  more 
probable — an  ulcer  with  inflammatory  hypertrophy,  the  future 
will  show.     She  is  now  in  admirable  health  (May,  1899). 

(d)  S.,  62  years,  wife  of  a  banker,  from  Hellerup,  near  Copen- 
hagen. Entered,  28.  4.  98.  Operation,  2.  5.  98.  Cystectomy, 
gastroenterostomy.      Discharged,  31.5.  98.      Cured. 

Amnesis. — The  history  is  scanty,  since  the  woman  speaks  but 
little  German.  One  learns  that  of  brothers  and  sisters  still  2 
sisters  live,  of  whom  one  is  epileptic.  Mrs.  S.,  mother  of  7 
living  children,  was  healthy  save  for  a  parametritis  sinistra.  Four 
years  ago  she  w^as  attacked  with  neuralgia  of  the  shoulder  ;  with 
its  cessation  pains  occurred  in  the  region  of  the  liver,  w^ith  it  a 
feeling  of  fullness  in  the  stomach,  besides  a  discharge  of  blood 
from  the  vagina.  The  pains  in  the  liver  lasted  all  the  time.  A 
cure  in  Kreuznach  in  the  year  1897  was  without  result.  After- 
ward Dr.  Halk,  in  Copenhagen,  was  consulted,  who  employed 
irrigation  of  the  stomach  with  temporary  improvement.  Since 
the  pains  again' occurred  in  the  region  of  the  liver  in  increased 
severity,  and  a  tumor  was  to  be  felt  beneath  the  left  border  of 
the  ribs,  it  was  concluded  to  consult  me  on  the  journey  to 
Carlsbad. 

Status  Prsesens. —  Medium-sized,  fairly-nourished  woman, 
nothing  special  in  heart  or  lungs.  One  can  almost  always  cause 
succussion  sounds  in  the  stomach,  of  which  the  upper  border  is 
at  the  curve  of  the  ribs  and  the  lower  after  siphonage  was  a  little 
below  the  navel.  Two  hours  after  a  trial-breakfast  siphonage 
discloses  still  a  good  deal  of  food  fragments.  Free  hydrochloric 
acid  is  demonstrable,  yet  only  with  several  examinations  0.4-0.53 
p.m.  In  the  gall-bladder  lively  sensitiveness  to  pressure.  In  the 
left  parasternal  line  one  feels  immediately  under  the  ribs  a  resist- 
ance unchanging  with  the  respiration,  concerning  the  nature  of 
which  one  cannot  become  clear.  Urine  free  from  albumin,  su- 
gar and  bile  pigment. 
26 


306  GALLSTONE  DISEASE.  1 

Diagnosis. — Gastropsia,  myasthenia,  perhaps  carcinoma  of 
the  stomach,  stones  in  the  gall-bladder. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision 
in  the  right  rectus  abdominal  muscle.  The  gall-bladder  is  adherent 
to  the  omentum,  and  is  dropsically  distended.  After  separation 
of  the  adhesions,  which  draw  the  gall-bladder  towards  the  left, 
it  immediately  empties  itself.  With  the  existing  enteroptosis  the 
extirpation  is  very  easy  and  almost  bloodless.  Double  ligature 
of  the  cystic  duct,  suturing  over  of  the  liver  bed  with  the  serosa. 
On  the  lesser  curvature  of  the  stomach  a  three-mark  sized 
hard  tumor  was  found,  which  as  such  would  have  been  easy  to 
remove,  but  on  account  of  the  presen(fe  of  numerous  enlarged 
glands  in  the  lesser  omentum  excision  was  not  done.  It  is  not 
to  be  positively  determined  what  kind  the  previously  felt  resist- 
ance was  (ulcer  or  carcinoma  ? ).  Gastroenterostomy  after 
Hacker  by  suture.  Fourfold  gauze  strips  down  to  the  stump  of 
the  cysticus,  through  and  through  interrupted  sutures  of  the 
abdominal  wall  as  far  as  the  angle  of  the  wound,  out  of  which 
the  gauze  is  brought. 

Gall-bladder  of  medium  size,  walls  thickened  by  inflammation, 
filled  with  mucus,  which  is  bile-colored  ;  one  large  stone  in 
the  neck. 

Course. — The  course  is  smooth,  the  evening  temperature 
never  goes  beyond  38°.  On  the  first  dressing  on  the  9.  5.  the 
large  wound  shows  itself  healed  by  first  intention.  The  sutures 
were  removed  on  the  12.  5.  98,  also  part  of  the  tampon  of  gauze, 
which  adheres  very  firmly,  so  that  the  remainder  is  first  removed 
on  the  16.  5.  Light  tampons  of  the  wound  with  sterile  gauze. 
Under  four  further  dressings  the  wound  is  completely  closed. 
Mrs.  S.  has  thoroughly  recovered,  and  is  discharged  on  the 
31.5.  98,  with  the  injunction  to  have  herself  still  bandaged  at 
her  home.  In  February,  1899,  very  good  news  arrives  concern- 
ing the  health  of  the  patient.      It  is  to  be  hoped  there  is  onh'  an 


ulcer 


(e)   L.  K.,  43   years,  widow,  from  Halberstadt.    Entered,  9.  2. 


CLINICAL  AND  OPERATION  HISTORIES.  307 

98.   Open,  10.  2.  98.      Pyloroplasty,  ectomy.      Discharged,   25. 
3.  98.     Cured. 

Amnesis. — Father  of  the  patient  is  dead,  mother  is  living 
and  suffers  from  gout,  2  still  living  sisters  are  healthy.  Patient 
married  at  22  years  old;  mother  of  6  children  ;  5  live  and  are 
healthy.  The  patient  is  said  not  to  have  been  ill  until  she  in 
1894  was  attacked  with  cramps  in  the  stomach,  associated  with 
jaundice.  The  attacks  were  very  rare,  indeed  in  the  beginning 
they  were  absent  often  i^  year.  Later  they  became  more  fre- 
quent, and  since  1898  they  have  already  occurred  3  times,  each 
time  attended  by  slight  jaundice.  The  attacks  consisted  of 
cramp-like  pains,  which  radiated  from  the  stomach,  and  later 
more  from  the  right  upper  abdominal  region  to  the  back  ;  their 
duration  extended  to  several  hours.  Usually  they  terminate 
with  vomiting.  After  eating  the  patient  often  has  a  feeling  of 
pressure  in  the  region  of  the  stomach,  much  eructation  and 
nausea.  She  does  not  suffer  from  vomiting  in  the  intervals  be- 
tween attacks.  The  bowels  are  said  to  be  constipated,  and  re- 
cently emaciation  has  occurred.  The  patient  is  no  longer  suffi- 
ciently able  to  work,  and  hopes  from  an  operation  a  restoration 
of  her  former  working  capacity. 

Status  Praesens. —  Medium  -  sized,  thin  woman.  Organs 
healthy,  no  jaundice.  Liver  not  palpable  ;  in  the  region  of  the 
gall-bladder  lively  sensitiveness  to  pressure.  The  lower  border 
of  the  stomach  is  shown  by  palpation  and  by  distension  with  air 
to  be  2  finger-breadths  below  the  navel. 

Diagnosis. — Cholelithiasis  and  dilatation  of  the  stomach. 

Operation. — Chloroform  anaesthesia.  After  the  occurrence  of 
relaxation  of  the  muscles  one  can  excite  marked  succussion  in 
the  stomach  although  the  patient  has  eaten  nothing  since  the 
evening  of  the  preceding  day.  Longitudinal  incision  in  the  right 
rectus  abdominal  muscle  from  curve  of  ribs  downward  to  2  cm. 
below  the  navel.  The  gall-bladder,  immediately  visible,  is  exten- 
sively adherent  to  the  omentum  ;  its  posterior  and  lateral  surface 
is  adherent  to  the  horizontal  part  of  the  duodenum  and  the  py- 


3o8  GALLSTONE  DISEASE. 

lorus.  After  the  in  part  bloody  separation  of  the  adhesions  the 
bladder,  which  feels  like  a  bag  filled  with  shot,  is  separated  from 
the  liver  with  violent  haemorrhage  until  the  cysticus  is  free.  A 
tear  in  the  liver  i  cm.  deep  arising  in  this  is  immediately  closed 
by  2  interrupted  silk  sutures.  After  clamping  of  the  gall-bladder 
and  double  ligature  of  the  cysticus  remo\-al  of  the  former.  The 
stump  of  the  cysticus  is  stitched  over  with  3  silk  sutures.  After 
provisional  tampon  of  the  liver  bed  the  stomach  is  inspected.  It 
is  dilated.  The  anterior  wall  of  the  pars  pylorica  and  that  of  the 
pars  horizontalis  duodeni  are  found  for  the  most  part  deprived 
of  the  serous  coat.  Pyloroplasty  by  transverse  suturing  of  5  cm. 
longitudinal  incision  of  the  corresponding  place  with  Lembert 
sutures  on  account  of  the  fear  of  subsequent  stenosis,  especiall}' 
as  there  exists  already  dilatation  of  the  stomach.  For  security 
a  flap  of  omentum  is  fixed  over  the  line  of  suture.  Now  tampon 
of  liver  wound  as  far  as  the  stump  of  the  cysticus  with  long 
strips  of  sterile  gauze,  wdiich  are  brought  out  of  the  upper  angle 
of  the  wound.  Closure  of  the  remainder  of  the  wound  by  through 
and  through  interrupted  silk  sutures  and  some  skin  sutures. 
Duration  of  the  operation,  50  minutes.  Course  is  smooth.  Only 
on  the  day  of  operation  did  the  temperature  reach  38°.  The 
tampon  is  removed  at  the  first  dressing  on  the  19.  2.  at  the 
same  time  as  the  sutures.  First  intention.  On  the  25.  3.  Mrs. 
K.  is  discharged  with  a  small  strip  of  granulations.  Under  2 
further  dressings  the  healing  is  complete.  The  woman  is  very 
well  satisfied  with  her  health  ;  she  vrears  an  abdominal  bandage. 


15. 
Gallstone   Ileus. 

The  following  histor}^  describes  sucli  a  case  : 

Mrs.  W.,  47  years,  from  Thale  a.  S.  Entered,  9.  i.  97.  Op- 
eration, 9.  I.  97.  Enterotom}'  on  account  of  gallstone  ileus. 
Discharged,  15.  i.  97.      Dead. 


CLINICAL  AND  OPERATION  HISTORIES.  309 

Mrs.  W.  was  sent  to  the  clinic  by  Dr.  Crohn  of  Halberstadt. 
She  is  said  to  come  from  a  healthy  family  and  never  to  have  been 
seriously  ill  ;  she  has  had  five  children.  A  year  ago  she  was 
attacked  with  violent  pains,  which  began  in  the  pit  of  the  stomach 
and  radiated  toward  the  back  and  the  right  axilla  ;  vomiting  did 
not  occur,  icterus  did  not  appear.  This  attack  lasted  2  hours. 
The  entire  time  before  as  after  this  colic,  according  to  the  assur- 
ances of  the  husband  and  the  patient  herself,  has  the  latter  never 
suffered  from  pains  in  the  stomach  and  irregularity  of  stools, 
only  there  existed  since  this  attack  a  continual  feeling  of  pres- 
sure in  the  coecal  region.  Then  suddenly  on  the  5.  2.  97  in 
afternoon  she  was  taken  with  violent  pains  in  the  region  of  the 
stomach,  in  the  evening  she  vomited  the  food  she  had  taken  ; 
flatus  and  stools  from  this  moment  no  longer  passed.  The  ab- 
domen began  to  distend.  Despite  the  purgatives  ordered  by 
the  physician  summoned,  oil  enemata,  and  high  irrigations,  no 
flatus  passed.  Vomiting  could  not  be  checked,  already  on  the 
6.  I.  evening  it  was  fecal.  This  condition  continued  until  9.  I. 
midday,  when  the  patient  was  referred  to  the  clinic. 

Status  Praesens, — Strong,  cyanotic  -  looking  woman;  no 
icterus  ;  tongue  thickly  coated,  somewhat  dry.  Heart  and  lungs 
normal.  The  abdomen  is  uniformly  strongly  distended,  tense, 
everywhere  tympanitic  resonance,  nowhere  dullness.  No  tumor 
to  be  felt,  no  sensitiveness  to  pressure.  Pulse  1 20,  small  and 
soft,  no  fever.     Urine  contains  nothing  abnormal. 

Diagnosis. — Obturation  ileus,  perhaps  caused  by  a  gallstone 
which  has  broken  into  the  intestine. 

Immediately  after  the  admission  of  the  patient  the  stomach 
was  washed  out ;  about  ^  a  pailful  of  fecal  fluid  was  washed 
out.  The  patient  felt  afterward  so  improved,  that  she  declared 
herself  well  and  would  absolutely  get  out  of  bed.  An  opera- 
tion proposed  was  refused.  High  irrigations  without  any  suc- 
cess. The  water  came  back  uncolored,  the  intestine  did  not 
contract.  In  the  evening  the  stomach  was  again  washed  out, 
there  had  collected  from   midday  on,  although  the  patient  had 


3IO  GALLSTONE  DISEASE. 

not  drank  a  drop,  still  again,  about  3  liters  of  fecal  fluid.  No 
passage  of  flatus.  Finally  on  persuasion  of  the  husband  consent 
was  given  for  an  operation. 

Operation  on  the  9.  i.  97,  half-past  8  o'clock  in  the  evening. 
Morphine-atropia-ether  anaesthesia.  Longitudinal  incision  in  the 
median  line  from  the  navel  downwards  to  the  symphysis.  On 
opening  the  abdomen  there  immediately  pushed  out  the  very 
distended  and  injected  but  not  coated  intestines,  which  could 
only  be  kept  back  with  difficulty.  The  hand  which  was  intro- 
duced felt  in  the  ccecal  region  a  circumscribed  movable  stony- 
hard  resistance  ;  the  intestinal  convolution  which  was  brought 
out  of  the  wound  proved  to  be  the  transitional  portion  of  the 
ileum  into  the  ccecum.  In  it  was  seated  a  somewhat  hen's-egg- 
sized  gallstone,  Avhich  was  removed  by  transverse  incision  of  the 
intestine.  The  incision  was  closed  by  a  double  row  of  sutures. 
Closure  of  the  abdominal  wound.  Duration  of  the  operation, 
I  y^  hours. 

Course. — The  patient  bore  the  operation  well ;  pulse  is  regu- 
lar, strong,  92  beats  in  the  minute.  Fever  is  not  present,  no- 
where sensitiveness  to  pressure  of  the  abdomen.  On  the  3d  day 
after  the  operation  the  patient  again  vomited  fecal  masses. 
Flatus  despite  enemata  of  glycerine  and  of  water  have  not  yet 
passed.  The  stomach  is  straightway  washed  out ;  towards  eve- 
ning despite  this  again  fecal  vomiting,  so  that  indeed  a  renewed 
operation  is  considered.  This  evening  the  temperature  reached 
38.3,  no  signs  of  peritonitis  present.  One  determines  to  wait. 
During  the  night  the  patient  gets  3  high  injections  ;  the  water 
of  one  injection  passes  fecal  colored,  that  of  the  others  un- 
changed. From  the  4th  day  after  the  operation  on  still  no 
passage  of  flatus,  moreover  the  patient  still  has  some  fecal  vomit- 
ing, although  peritonitis  is  to  be  excluded,  3  tablespoonfuls  of 
castor  oil  were  introduced  into  the  stomach  after  it  had  been 
washed  out  in  order  to  furnish  proof  whether  the  bowel  was 
patent  or  not  and  in  order  to  meet  the  indications.  No  vomit- 
ing followed  ;  at  9  o'clock  in  the  evening  again  a  high  irrigation. 


CLINICAL  AND  OPERATION  HISTORIES.  3  II 

afterwards  passage  of  flatus.  On  the  succeeding  deiy  abundant 
discharge  of  feces  and  passage  of  flatus  ;  belly  is  soft,  no  longer  dis- 
tended ;  no  fever  ;  no  vomiting.  Patient  is  weak,  mucus  collects 
in  the  bronchi.  With  increasing  weakness  death  ensued  on  the 
15.  I.  at  half-past  twelve  midday,  after  that  on  account  of  the 
oedema  of  the  lungs  a  bleeding  had  previously  been  made. 

No  autopsy.      Death  probably  occurred  from  intoxication  due 
to  the  long  existing  ileus. 


16. 

The  Difficulty  and  Impossibility    of   Special  Diagnoses  in 
Certain  Cases. 

If  Kolisch  (Wiener  med.  Klub,  Sitzungun  vom  7.  und  14. 
Dec.  1898.  Centralbl.  f.  d.  Grenzgebiete  der  Medizin  und 
Chirurgie  II.  Bd.  No.  6,  p.  253),  calls  attention  to  this  "that  the 
framing  of  indications  for  operation  from  the  anatomical  data  is 
for  practice  worthless,  since  many  cases  in  life  are  not  to  be  diag- 
nosticated with  anatomical  accuracy,  and  even  if  it  were  possible 
they  would  be  differently  circumstanced  with  reference  to  opera- 
tion, since  many  could  wait  a  long  time  and  others  would  have 
to  be  operated  upon  as  soon  as  possible," — thus  I  reply  to  this 
that  with  sufficient  training  and  experience  it  is  possible  to  frame 
an  anatomical  diagnosis  and  with  it  also  the  indications  for 
operation  in  the  vast  majority  of  cases.  Upon  what  then  should 
we  actually  found  our  indications  for  operation  ?  The  pains  can- 
not always  be  the  standard,  for  they  are  wanting  frequently  there 
where  an  operation  is  very  necessary  (in  chronic  obstruction  of 
the  choledochus)  and  are  very  violent  where  one  ought  not  to 
operate  (acute  obstruction  of  the  choledochus).  The  data  from 
examination  may  prove  absolutely  negative  and  yet  the  gall- 
bladder conceal  pus  within  itself.  Jaundice  and  fever  are  so 
variable  that  it  is  difficult  upon  the  basis  of  these  symptoms  to 


312  GALLSTONE  DISEASE. 

form  a  resolution  to  operate.  JVc  nuist  upon  the  foundation  of 
the  amncsis,  of  tJic  previous  course  of  the  disease,  and  the  data  to  be 
obtained  by  an  immediate  examination,  seek  to  construct  a  picture 
of  the  anatomical  condition  ivJiicJi  zve  expect  to  find  in  the  case  in 
point  and  frame  an  anatomical  diagnosis.  Only  in  this  wise 
will  we  advance  the  special  diagnosis  of  cholelithiasis  and  learn 
to  frame  the  correct  indications  for  medical  or  surgical  treatment. 
I  am  also  of  an  entirely  opposite  opinion  to  Kolisch,  but  I  do 
not  deny  that  in  a  series  of  cases  it  is  entirely  impossible  to  frame 
an  anatomical  diagnosis  and  a  strict  indication  for  operation. 

Some  examples  may  throw  light  upon  the  difficidty  and  impos- 
sibility of  making  a  correct  diagnosis  of  cholelithiasis. 

A  very  instructive  case  in  this  respect  is  the  following  : 

Mrs.  Fr.,  ^6  years,  from  Cothen.  Entered,  lo.  i.  99.  Oper., 
II.  I.  99.  Ectomy,  pyloroplasty,  gastroenterostomy.  Dis- 
charged, 8.  2.  99.      Cured. 

Amnesis. — Mother  of  the  patient  is  living  and  suffers  accord- 
ing to  her  physician's  diagnosis  from  gallstones  ;  father  dead. 
Mrs.  P.,  otherwise  healthy,  as  a  child  had  jaundice  and  as  a 
young  girl  already  had  cramps  in  the  stomach.  After  her  sec- 
ond confinement  very  violent  colic  and  jaundice  of  3  days'  dura- 
tion. The  physician  at  that  time  diagnosticated  gallstones. 
Afterward  her  health  was  good  save  for  slight  attacks  of  cramps. 
Two  years  ago  frightful,  almost  daily  colics  without  jaundice  ; 
the  attacks  of  pain  lasted  about  2  months  ;  since  then  the  patient 
has  felt  a  sufferer.  In  the  year  1898,  November,  hard  places  were 
felt  in  the  region  of  the  liver,  the  stomach  was  very  sensitive. 
Colics  did  not  occur  again,  but  there  always  exists  a  dragging  in 
the  back  and  pain  in  the  region  of  the  shoulders.  In  the  last  10 
weeks  the  pain  was  in  the  spine  in  early  morning  before  rising, 
more  or  less  violent,  and  distressed  the  patient  very  much.  Her 
stomach  at  the  present  is  well.  The  patient  comes  hither  upon 
the  advice  of  Dr.  Fitzau.  Examination  negative  ;  only  in  the 
region  of  the  gall-bladder  slight  painfulness  and  resistance. 

Diagnosis, — Stones  in  the  gall-bladder.      Cysticus  at  present 


CLINICAL  AND  OPERATION  HISTORIES.  313 

free.  Operation,  11.  i.  99.  Gall-bladder  small,  intimately  ad- 
herent to  the  pylorus.  In  the  fundus  of  the  gall-bladder  a 
walnut-sized  stone,  and  several  small  ones.  In  the  pylorus, 
which  is  adherent  to  the  fundus,  there  is  found  on  separating  ad- 
hesions a  pea-sized  defect  which  is  excised.  Pyloroplasty.  Since 
the  pylorus  appears  very  narrow,  in  addition  gastroenterostomy 
after  von  Hacker.  Ectomy  of  the  gall-bladder.  Separate  liga- 
tion of  the  arteria  cystica  and  the  cystic  duct.  Tamponade. 
The  longitudinal  incision  in  the  right  rectus  abdominal  muscle 
has  sufficed  for  the  gastroenterostomy.  Very  difficult  2)^  hour 
operation. 

Very  smooth,  faultless  course.  No  vomiting.  Can  already  on 
the  8th  day  after  operation  eat  everything  Dressing  remains  14 
days.  No  more  traces  of  pain.  Discharged  in  admirable  good 
health. 

Remarks. — The  patient  had  at  the  time  only  pains  in  the  back, 
and  yet  one  found  extensive  changes  brought  about  by  a  stone 
attempting  to  break  through.  How  can  one  in  such  cases  frame 
a  diagnosis  and  indications  for  operation  ?  How  can  one  know 
that  in  this  or  that  case  a  natural  cure  is  actually  going  on  ?  I 
have  exactly  in  this  case  again  seen  that  the  distinction  between 
regular  and  irregular  cholelithiasis  is  not  at  all  possible,  and  that 
the  indication  for  operation  is  first  to  be  made  often  after  the 
ope.:ing  of  the  abdomen  or  the  clearing  up  of  the  existing  patho- 
logical condition.  To  operate  early,  so  long  as  the  stones  have 
not  yet  given  rise  to  severe  changes,  is  surely  the  most  correct 
standpoint.  In  the  following  case  violent  colics  have  indeed  pre- 
ceded, but  the  results  of  examination  were  almost  negative.  Of 
the  coexistent  affection  of  the  colon  no  one  dreamed.  A  positive 
diagnosis  was  impossible  ;  the  patient  himself,  upon  the  ground  of 
his  distress,  gave  the  indication  for  operation. 

^^'  J'>  33  years,  from  Gotha.  Entered,  19.  7.  97.  Opera- 
tion, 21.7.  97.  Cystectomy,  enteroentcrostomy.  Discharged, 
19.  8.  97.      Cured,  6.  9.  97. 

Amnesis. — Father  of  the  patient  died  of  diabetes,  mother  is 


314  GALLSTONE  DISEASE. 

living  in  health.  Patient  himself  was  never  very  ill  until  the  30th 
year  ;  he  suffered  at  22  from  a  mild  catarrhal  jaundice.  The  be- 
ginning of  the  present  trouble  was  with  at  first  rarely,  later  fre- 
quently occurring  pains  in  the  stomach,  which  appeared  espe- 
cially after  slight  errors  in  diet  ;  always  real  improvement  after 
vomiting.  With  it  already  in  February,  1894,  occurred  quite 
often  obstinate  constipation.  First  in  the  autumn,  1895,  occurred 
more  colic-like  pains,  which  directed  a  suspicion  towards  gall- 
stones. The  winter  of  1895-96  brought  a  great  number  of  such, 
in  part  right  painful  attacks  ;  pains  in  the  stomach  and  region  of 
the  liver,  radiating  toward  the  back.  Duration  of  the  attacks 
usually  only  a  few  hours,  then  vomiting  and  improvement. 
April-May,  1896,  4  weeks'  cure  in  Carlsbad.  During  this  time 
and  the  following  summer  relatively  good  health  which  con- 
tinued until  Christmas,  1896.  On  the  25th  of  December  a  very 
severe  attack  of  some  3  hours'  duration,  10  days  later  a  some- 
what milder  one,  then  again  relatively  little  distress.  May,  1897, 
second  Carlsbad  cure.  This  time  there  was  little  good  health  ; 
no  colic-Hke  pains,  but  a  feeling  of  great  collection  of  gas  in  the 
abdomen,  which  was  situated  in  a  definite  place,  usually  some- 
what to  the  right  of  the  navel,  and  caused  a  painful  pressure. 
With  it  a  slight  loss  of  bodily  weight  from  65  kilo,  to  6^}4- 
This  distress,  intermixed  with  slight  colic-like  pains  now  particu- 
larly radiating  towards  the  back,  did  not  let  up  after  the  com- 
pletion of  the  Carlsbad  cure,  and  caused  a  marked  diminution 
of  strength  and  great  nervous  irritability.  Therefore  he  decided 
upon  operation. 

Status  Praesens. — Thin,  markedly  emaciated  man  ;  no  jaun- 
dice, heart  and  lungs  normal.  In  the  gall-bladder  slight  sensi- 
tiveness to  pressure.  Liver  and  spleen  not  enlarged.  No  fever  ; 
pulse  regular,  strong,  yy  beats  in  the  minute.  The  urine  con- 
tains no  abnormal  constituents.      Stools  normal. 

Diagnosis. — Old  gallstone  disease  ;  adhesions. 

Operation  on  the  21.7.  97.  Chloroform  anaesthesia.  Longi- 
tudinal incision  in  the  right  rectus  abdominal  muscle  from  curve 


CLINICAL  AND  OPERATION  HISTORIES.  315 

of  ribs  downward  to  die  navel.  On  opening  the  belly  there 
appeared  a  medium-sized,  slightly  filled  gall-bladder  adherent  to 
the  omentum  by  broad  adhesions.  Their  separation  succeeds 
easily.  In  the  gall-bladder  a  number  of  pea-sized  stones  are  to 
be  felt.  Extirpation  of  the  gall-bladder.  In  part  bluntly,  in 
part  with  the  knife,  it  is  freed  from  its  liver  bed,  at  the  cysticus 
ligated  and  then  removed.  Sewing  over  of  the  stump  of  the  cys- 
tic duct.  On  palpating  the  abdominal  cavity  a  circumscribed 
thickening  appears  near  the  ccecum.  It  is  a  markedly  swollen 
mesenteric  gland.  Coexistent  thickening  and  narrowing  of  the 
ascending  colon  (tuberculosis  ?).  For  this  reason  (beginning  in- 
testinal stenosis  from  tuberculosis)  a  communication  was  made 
between  the  transverse  colon  and  ileum  by  enteroenterostomy. 
Removal  of  the  gland.  Down  to  the  stump  of  the  cystic  duct 
a  long  tampon  is  pushed.  Now  follows  special  peritoneal  mus- 
cle and  skin  suture.  Through  a  small  opening  of  the  abdominal 
wound  the  tampon  is  brought  out.  Dressing.  Duration  of  the 
operation,  i  ^  hours. 

Course. — Patient  bore  the  operation  well.  The  first  few  days 
he  was  very  much  plagued  with  vomiting  (chloroform)  and  vio- 
lent singultus.  Highest  evening  temperature,  38.2°  ;  pulse 
strone",  refjular,  highest  number  of  beats  lOO.  On  the  first 
dressing,  which  was  done  on  the  30.  7.,  after  the  removal  of  the 
tampon  a  good  granulating  wound  cavity  appears,  in  the  bottom 
the  stump  of  the  cysticus  is  visible  ;  not  a  trace  of  bile  in  the 
dressings.  The  abdominal  wound  looks  somewhat  irritated,  the 
sutures  are  removed,  from  the  stitch  openings  some  drops  of 
pus.  ■  From  day  to  day  the  condition  of  the  patient  improves 
more  and  more  ;  on  account  of  abscesses  of  the  abdominal  walls 
daily  dressings  are  made  until  18.  8.  A  number  of  sutures  are 
expelled.  Discharged  from  the  clinic  on  the  19.  8.  Last  ap- 
pearance on  the  6.  9.  wound  well  healed,  no  ventral  hernia.  The 
beginning  of  February,  1898,  news  received  reports  that  every- 
thing goes  well  with  the  patient.  In  August,  1898,  the  patient 
has  pain  in  the  operation  scar,  and  fever.     An  abscess   formed 


3l6  GALLSTONE  DISEASE. 

which  was  incised.  Silk  sutures  were  discharged  with  the  pus. 
Then  good  health.  In  February,  1899,  ^  ^^^^'  ^^^  patient  in 
flourishing  health. 

In  the  following  case  one  positively  believed  he  would  find 
stones  in  the  iiiflaincd  gall-bladder,  but  found  only  stasis  in  a 
gall-bladder  divcrtiailaiiy  like  degenerated  from  adhesions. 

Mrs.  A.,  41  }'ears,  from  Halberstadt.  Entered,  7.  3.  99. 
Operation,  8.  3.  99.  Cystectomy  of  a  diverticulated  gall-blad- 
der.     Discharged,  6.  4.  99.      Cured. 

Amnesis. — Family  history  without  importance.  Mrs.  A.  is 
said  as  a  child  to  have  been  healthy,  married  at  20  years  old, 
mother  of  2  children  of  which  one  is  living.  Two  miscarriages. 
Probably  endometritis  (?),  4  or  5  years  ago  distress  in  the 
stomach,  apparently  cramps  of  the  stomach,  with  them  rarely 
vomiting,  usually  only  nausea  and  dizziness;  "gallstone  colic" 
for  the  first  time  four  years  ago  ;  treatment  heretofore  poultices 
and  morphine.  Appetite  was  variable.  The  cramps  in  recent 
years  were  of  short  duration  and  of  little  severity,  but  there  has 
existed  always  a  concealed  dragging  in  the  region  of  the  liver. 
The  last  severe  attack  was  on  the  5.3.  99,  and  consisted  princi- 
pally of  pains  in  the  back,  dizziness  and  headache  ;  it  is  said 
Mrs.  A.  fainted.  Since  then  abatement  of  symptoms.  Com- 
plete loss  of  appetite.  Four  years  ago  Mrs.  A.  is  said  to  have 
been  jaundiced,  otherwise  never.  Stools  variable,  now  consti- 
pation, now  diarrhoea.      Dr.  Philipp  advised  operation. 

Status  Praesens. — Liver  not  enlarged,  gall-bladder  clearly  to 
be  felt  as  an  egg-shaped,  very  painful  tumor.  On  the  next  day 
the  tumor  is  gone.      Nothing  pathological  in  urine.      No  fever. 

Diagnosis. — Cholecystitis  serosa  acuta,  7.  3.  99.  Stone  in 
the  gall-bladder.      Cysticus  now  free,  8.  3.  99. 

Operation. — Longitudinal  incision  in  the  right  rectus  abd. 
muscle,  15  cm.  long.  Gall-bladder,  not  enlarged,  extensively 
adherent,  is  freed  ;  no  stones  demonstrable.  The  neck  of  the 
gall-bladder  is  distended  like  a  cyst,  one  may  almost  speak  of  a 
double  gall-bladder.      Ectomy  without  much  bleeding.     Sound- 


CLINICAL  AND  OPERATION  HISTORIES.  317 

ing  of  cysticus  and  choledochus  negative.  Independent  ligature 
of  .the  cystic  duct  of  the  septic  arteiy.  Pylorus  sufficiently 
patent.  Tampon  of  the  liver  bed.  Lower  part  of  the  wound 
closed  by  interrupted  through  and  through  sutures.  Gall-blad- 
der healthy,  contains  clear  bile.  Duration  of  the  operation,  y> 
hour. 

The  bile,  taken  with  all  aseptic  precautions,  shows  itself  free 
from  germs.  In  this  case  the  frightful  pains  had  led  to  the  diag- 
nosis of  acute  inflammation,  of  which  no  trace  was  found.  The 
pain  was  solely  caused  by  the  stasis  of  the  bile  in  the  gall-blad- 
der from  the  kinking  of  the  cysticus  ;  it  was  a  case  of  colic  of 
purely  nicclianical  cliaractcr.  The  gall-bladder  the  day  before 
operation  was  very  clearly  to  be  felt  as  an  elastically  distended 
tumor.     Under  anaethesia  nothing  else  to  be  felt. 

The  diagnosis  was  also  wrong,  yet  the  operation  was  very  nec- 
essary, since  only  in  this  way  could  the  patient  be  cured  of  her 
pain.  A  right-sided  pleuropneumonia  of  the  lower  lobe  dis- 
turbed somewhat  the  otherwise  smooth  course.  Discharged  on 
the  6.  4.      Cured. 

In  the  following  case  I  did  not  find  the  imagined  adhesions. 
With  the  constant  feeling  of  pressure  in  the  region  of  the  gall- 
bladder, which  became  worse  especially  after  meals,  I  was  sure 
of  adhesions,  and  was  astonished  at  Ihe  operation  to  find  none  of 
them.  A)i  absolntely  certain  criterion  of  adhesions  does  not 
exist. 

Dr.  C,  42  years,  from  New  York,  at  present  in  Berlin.  En- 
tered, 14.  9.  96.  Oper.,  16.  9.  96.  Cystopexy.  Discharged, 
8.  10.  96.      Cured. 

Patient  is  said,  except  for  malaria,  to  have  had  no  severe  ill- 
ness. For  twelve  years  he  has  suffered  with  his  stomach. 
Especially  after  eating  fatty  foods  pains  in  the  stomach  and  vom- 
iting occurred.  In  the  gall-bladder  there  was  always  a  feeling  of 
pressure ;  bowels  constipated,  passages  only  with  laxatives. 
Jaundice  never  present. 

Status  Prsesens.— Thin,  medium-sized  man  of  moderate  con- 


3l8  GALLSTONE  DISEASE. 

dition  of  nutrition.  No  icterus.  Examination  of  the  heart  dis- 
closes that  the  apex  beat  is  in  the  6th  intercostal  space,  diffusi^d, 
and  is  distinctly  to  be  felt  in  the  papillary  line.  The  heart  is  not 
enlarged  above  and  to  the  right.  Heart-sounds  pure,  2d  pulmonic 
appears  a  little  accentuated.  Lungs  normal.  In  the  gall-blad- 
der there  is  sensitiveness  to  pressure  ;  no  palpable  tumxor.  Liver 
not  enlarged.  Pulse  is  regular,  strong,  "j^  beats  in  the  minute. 
Temperature  normal.  Stools  brown,  uriiie  light-yellow  ;  con- 
tains no  albumin,  sugar  nor  bile  pigment. 

Diagnosis. — Gallstones  in  the  gall-bladder.      Adhesions. 

Operation  on  the  i6.  9.  96.  Morphine-atropine-ether  anaes- 
thesia. Longitudinal  incision  in  the  right  rectus  abdom.  mus. 
On  opening  the  belly  there  appeared  high  up  on  the  under  sur- 
face of  the  li\'er  the  medium-sized  gall-bladder,  free  from  adhe- 
sions. On  palpation  of  the  gall-bladder  one  detects  a  hazelnut- 
sized  solitary  stone.  The  gall-bladder  is  opened  and  the  stone 
extracted.  Cysticus  and  choledochus  free  from  stones  ;  in  the 
gall-bladder  clear,  viscid  bile.  After  the  suggestion  of  Czerny 
the  gall-bladder  previously  closed  with  suture,  and  of  which  the 
walls  show^  no  pathological  changes,  is  so  sutured  to  the  parietal 
peritoneum  that  its  fundus  is  shut  out  of  the  abdomen  (cysto- 
pexy).      Duration  of  the  operation,  ^  hour. 

17.  9.  96.  Patient  has  vomited  very  little,  feels  fairly  well. 
No  fever,  belly  soft.  18.  9.  96.  General  condition  good;  vom- 
iting ceased.  To-day  flatus  first  passes.  26.  9.  96.  Change  of 
dressings.  The  wound  has  healed  without  reaction.  The  sutures 
are  removed,  no  stitch-hole  suppuration.  Regular  stools  ;  no 
pains.  27.  9.  96.  To-day  temperature  38.4°.  Pulse  regular, 
strong,  94  beats.  Profuse  diarrhoea  occurs — 8  stools  in  the  day. 
Calomel,  0.2.      2  powders.      Diet. 

29.  9.  96.  Patient  completely  free  from  fever.  No  more 
diarrhoea.  Great  weakness,  i.  10.  96.  Strength  has  returned 
again.  Temperature  normal.  Patient  gets  light  solid  food. 
The  good  health  continues  so  that  the  patient  could  be  dis- 
charged on  the  8.  10.  96  as  cured. 


CLINICAL  AND  OPERATION  HISTORIES.  319 

With  the  excessive  nervousness  from  which  the  patient,  whose 
chnical  history  now  follows,  had  to  suffer,  I  would  not  have  been 
astonished  had  I  found  no  gallstones, 

C.  W.,  42  years,  post-office  cashier's  wife,  from  Mulheim  a. 
Rhein.  Entered,  23.  11.  97.  Operation,  24.  11.  97.  Cystec- 
tomy.     Discharged,  5.  i.  98.      Uncured. 

Amnesis. — The  letter  sent  me  by  the  attending  physician,  Dr. 
Wirz,  says  :  "  Mrs.  W.  has  suffered  for  years  from  gallstone 
colics,  which  so  long  as  the  patient  has  been  under  my  care, 
since  April  of  this  year,  have  recurred  every  14  days  to  3  weeks. 
Seldom  have  we  had  intervals  during  this  summer  of  i  to  5 
weeks.  On  the  other  hand  in  July  one  attack  followed  another. 
The  attacks  always  occurred  with  exceedingly  great  violence, 
were  accompanied  by  severe  vomiting  and  violent  pains  in  the 
shoulders,  and  sometimes  followed  by  chills.  Slight  icteric  color 
of  sclerse  occurred  always  after  the  violent  attacks.  Large  doses 
of  morphine — in  recent  times  in  doses  of  0.015 — must  be  given 
often  after  another,  to  cut  short  the  attacks. 

*'  I  regard  it  as  not  improper  to  remark  that  the  patient  bears 
morphine  only  in  combination  with  atropine  (to  o.  i  morphine, 
0.00 1  atropine).  The  most  violent  vomiting  follows  every  injec- 
tion of  morphine,  if  the  patient  does  not  previously  get  cerium 
oxalate  in  large  doses  (0.6-1.0).  These  doses  and  larger  even 
were  well  borne  b}'  her.  The  same  experience  I  had  with  her 
on  an  incidental  attempt  at  chloroform  anaesthesia,  to  which  she 
likewise  immediately  responded  with  violent  vomiting.  Gall- 
stones have  never  been  found  after  the  attacks,  although  a 
blackish  sand,  which  the  patient  will  show  you." 

Status  Prsesens. — Medium-sized,  corpulent  woman.  Organs 
normal.  Urine  free  from  albumin,  sugar  and  bile  pigment.  In 
the  gall-bladder  region  marked  sensitiveness  to  pressure,  but  no 
results  from  palpation,  since  the  abdominal  walls  are  always 
tense.     Patient  seems  to  be  very  nervous. 

Diagnosis. — Cystolithiasis. 

Operation.— Chloroform   anaesthesia.      Longitudinal    incision 


320  GALLSTONE  DISEASE. 

* 

in  border  of  the  right  rectus  abdominal  muscle.   The  gall-bladder 

appears  filled  with  3  large  stones  ;  its  walls  are  very  thick.  The 
suturing  is  very  difficult ;  it  is  preferred  to  do  the  extirpation 
with  regard  to  the  pathological  change  in  the  walls  of  the  gall- 
bladder. Cystic  artery  ligated.  Tamponade  of  the  liver  bed 
and  stump  of  the  cysticus.  Closure  of  the  abdominal  wound. 
Peritoneal-fuscial  and  muscle  suture.  Skin  wound  remains  open, 
up  to  the  exit  of  the  gauze.  The  gall-bladder  walls  not  thick- 
ened. Contents  of  the  gall-bladder  3  large  stones  and  very 
thick  brown  bile.  Discharged  with  small  strip  of  granulations 
and  abdominal  bandage  after  a  smooth  course.  The  patient  has, 
despite  the  faultless  healing  of  the  wound,  always  very  many 
complaints  ;  her  nervousness  has  become  no  better. 

An  absohitely  certain  diagnosis  was  not  possible  in  the  follo\\'ing 
case.  That  there  should  be  gallstones  seemed  very  improbable 
to  me. 

Mrs.  M.,  32,  wife  of  an  engineer,  from  Magdeburg.  Entered, 
16.  3.  99.      Discharged,  17.  3.  99. 

Amnesis. — Parents  have  had  no  stomach  or  similar  diseases  ; 
mother  died  in  an  insane  asylum  ;  father  is  still  living  in  good 
health.  Mrs.  M.  was  as  a  child  healthy,  taking  it  all  in  all ;  she 
suffered  at  one  time  from  diarrhoea,  and  had  to  often  complain 
of  a  bad  stomach  ;  pains  in  the  stomach  did  not  occur.  Patient 
married  4  years  ago  (Sept.,  1894);  mother  of  2  children;  the 
first  is  living  and  healthy,  the  second  died  at  7^  months,  as  she 
says  of  water  on  the  brain  (tuberculosis?).  Mrs.  M.,  who  never 
before  had  suffered  from  jaundice,  fell  ill  on  the  6th  day  of  her 
confinement  (31  May,  1898)  with  a  faint — apparently  collapse — 
which  left  after  it  dyspnoea,  which  lasted  a  couple  of  hours  ; 
sometimes  vomiting  occurred.  Since  then  the  patient  has  felt 
weak  ;  she  had  a  few  days  later  \omiting  with  pain  in  the  right 
side;  some  10  days  later  jaundice  appeared,  after  a  chill  had 
preceded  it.  The  chills,  according  to  statement,  of  i  5  minutes' 
duration,  appeared  every  3  or  4  days,  over  a  period  of  about  4 
weeks.      Constant  pain  in  the  region  of  the   stomach  and  right 


CLINICAL  AND  OPERATION  HISTORIES.  32 1 

upper  part  of  the  abdomen  existed  during  the  time,  and  are  said 
to  have  diminished  after  the  chills.  The  liver  is  said  to  have 
been  enlarged.  The  pains  and  chills  disappeared,  and  the  jaun- 
dice remained  approximately  unchanged  in  its  degree  until 
autumn  1898.  The  previous  colorless  passages  now  became 
again  darker.  The  jaundice  diminished,  the  general  condition 
improved.  In  January,  1899,  the  jaundice  again  became  marked, 
without  that  pains  had  occurred.  The  bodily  weight  had  fallen 
(about  30  pounds).  Until  now  the  jaundice  has  continued,  no 
pains,  the  appetite  is  good,  weakness.  The  attending  physician 
assumes  gallstones,  and  recommends  on  this  account  the  patient 
to  enter  my  clinic. 

Status  Prsesens. — Thin  woman.  Intense  jaundice.  Color  of 
skin,  grey-green.  Liver  markedly  enlarged,  extends  a  hand's 
breath  beyond  the  right  ribs.  Upper  surface  smooth  and  liver 
border  sharp.  Free  ascites  in  abdomen.  Spleen  markedly  en- 
larged. Apex  of  left  lung  infiltrated.  (Dullness,  bronchial  con- 
cretions.) Heart  normal.  Stools  grey,  urine  brown,  contains 
bile  pigment,  no  sugar,  no  albumin. 

Diagnosis  is  made  of  tuberculosis  of  the  peritoneum,  with 
particular  implication  of  the  glands  of  porta  hepatis  (or  pan- 
creas). 

With  tuberculosis  of  the  lungs  (in  sputum  tuberculosis  bacilli 
are  detected)  an  operation  is  very  risky.  If  one  determines  upon 
an  operation  at  all  events,  then  one  must  open  the  abdomen  un- 
der Schleich's  anaesthesia,  evacuate  the  ascites,  in  the  hope  that 
through  this  the  peritonitis  would  be  healed.  However,  the 
chances  for  a  cure  are  very  poor  ;  a  cholecystenterostomy,  in 
order  to  set  aside  the  jaundice,  is  an  operation  which  has  for  me 
little  attraction.  The  attending  physician  had  indeed  at  first 
thought  of  a  chronic  obstruction  of  the  choledochus  by  stone  ; 
although  he  in  his  letter  to  me  made  no  mention  of  any  definite 
diagnosis,  yet  he  had  prepared  the  patient  for  an  operation.* 

*  The  patient  came  on  the  23.3.  again  into  the  clinic  with  the  urgent  desire  for  an 
operation.   Under  Schleich's  anaesthesia  a  cystogastrostomy  was  performed.   Discharge 
27 


322 


GALLSTONE  DISEASE. 


In  the  following  case  I  experienced  a  very  surprising  condition. 

Tiibcradosis  of  the  peritoneum  and  dropsy  of  the  gall-bladder. 
With  the  slight  ascites  neither  the  attending  physician  nor  I  had 
dreamed  of  tubercular  peritonitis. 

Mrs.  O.,  41  years,  from  Altenburg  a.  S.  Entered,  20.  6.  98. 
Operation,  22.  6.  98.  Cystectomy.  Tubercular  peritonitis. 
Discharged,  31.  7.  ^^. 

Amnesis  written  down  by  Dr.  Renter.  *'  Thin  woman  up  till 
her  marriage  (1882),  especially  healthy.  First  4  children  easily 
born,  lying-in  without  disturbance.  Seven  years  ago,  in  1891, 
by  a  misstep  a  miscarriage  occurred  at  2  months,  which  was 
ended  by  assistance.  14  days  afterwards,  as  she  says,  fever  and 
chills,  then  recovery.  In  1893,  also  2  years  after  the  above 
abortion,  again  pregnant.  Hydatid  mole,  which  was  removed 
by  curettage  of  the  uterus — according  to  Mrs.  O.  In  addition 
to  this  a  catarrh  of  the  bladder  set  in,  which  necessitated  a  cure 
at  Bad  Wildung.  In  the  year  1895  the  patient  had  been  con- 
fined to  bed  3  weeks  with  a  kidney  trouble  (according  to  de- 
scription perhaps  stone).  On  the  3d  day  after  getting  out  of 
bed  suddenly  vomiting,  very  violent  pains  in  the  stomach  with 
subsequent  jaundice,  which  lasted  6  weeks.  Severe  pains  in  the 
region  of  the  liver.  Clay-colored  stools.  After  this  time  oc- 
casionally jaundice,  pains,  etc.  Since  the  end  of  1897  there  occur 
from  time  to  time  transitory  pains  with  slight  jaundice.  Up  till 
then  Geheim  Medicinrat  F.  was  the  attending  physician. 

"  Shortly  before  Christmas  the  patient  came  to  me  on  account 
of  persistent  severe  pains  in  the  region  of  the  liver  (region  of 
the  gall-bladder)  without  jaundice,  and  I  gained  the  impression 
of  a  stone  impacted  in  the  ductus  cysticus.  The  gall-bladder 
was  clearly  palpable,  very  painful  on  pressure.     The  pains  have 


of  the  patient  in  3  weeks  in  improved  condition.  Ascites  relieved  ;  jaundice  less. 
The  gall-bladder  was  found  at  the  operation  very  much  distended  ;  in  the  course  of 
the  ligamentum  hepatico-duodenale  many  glands  and  tuberculosis  especially  extended 
on  the  parietal  peritoneum.  The  operation  had  caused  the  patient  almost  no  pain  ; 
for  such  cases  the  Schleich's  anaesthesia  is  absolutely  ideal. 


CLINICAL  AND  OPERATION  HISTORIES. 


323 


then  again  let  up,  but  the  sensitiveness  to  pressure  remained. 
On  the  3.  2.  98  again  violent  pain,  jaundice,  vomiting.  Since 
tlic  beginning  of  March  there  now  exists  continuous  pain  in  the 
region  of  the  liver ;  oil  treatment — Carlsbad  salts  are  not  borne 
— brought  only  increased  pain  with  transient  jaundice.  The 
pain  in  the  gall-bladder  remained.  Two  and  one-half  weeks  ago 
the  pain  in  the  region  of  the  gall-bladder  was  extraordinarily 
violent,  the  pains  radiated  especially  downwards  towards  the 
ccecal  region,  and  the  most  delicate  touch  was  extraordinarily 
painful.  Only  ice  and  later  Priessnitz  in  combination  with 
opium  and  liquid  diet  brought  relief.  Absolute  rest  in  bed 
strongly  urged.  Slight  fever  elevations.  Now  a  marked  im- 
provement began,  only  the  gall-bladder  which  is  felt  as  a  resist- 
ance is  to  pressure  still  painful.  Pains  in  the  spleen.  This  is 
the  present  condition." 

Status  Prsesens. — Medium-sized,  thin  woman.  Results  of 
examination  of  organs  normal,  except  for  a  suspicious  bronchial 
catarrh  in  the  right  apex  of  the  lungs.  On  the  right  from  the 
rectus  abdominal  muscle  tumor  palpable  (dropsy  or  tubercular 
deposits),  resistance  4  finger^ breadths  above  the  symphysis  in 
the  middle  line  and  one  each  side  above  and  outwards.  Urine 
normal. 

Diagnosis. — Adhesions  of  the  gall-bladder.  Calculus  chole- 
cystitis. 

Operation. — Chloroform  anaesthesia.  Longitudinal  incision  in 
the  right  rectus  abdominal  muscle  at  the  curve  of  the  ribs  length- 
ened upwards  and  extending  to  below  the  navel.  Extensive  ad- 
hesions. Slight  amount  of  clear  fluid  in  the  abdominal  cavity,  ex- 
tensive tubercular  peritonitis,  dropsy  of  the  gall-bladder  kinked  by 
adhesions,  separation  of  adhesions,  separation  of  the  under  surface 
of  the  right  lobe  of  the  liver  which  is  entirely  imbedded  in  ad- 
hesions ;  but  little  bleeding  in  the  extirpation  of  the  stone  free, 
inflamed  gall-bladder,  which  contains  slimy  secretions,  double 
ligature  of  the  cystic  duct.  Separation  of  the  lumpy  thickened 
omentum  from  the  lower  anterior  abdominal  wall.     Tampon  of 


324 


GALLSTONE  DISEASE. 


the  cysticus  stump  and  liver  bed.  Closure  of  the  abdominal 
wound  with  interrupted  through  and  through  sutures  and  some 
skin  sutures  up  to  the  exit  of  the  gauze. 

The  course  is  admirable  by  reason  of  the  absence  of  tempera- 
ture elevation  ;  the  highest  evening  temperature  remains  under 
38°.  On  the  I.  7.  the  first  change  of  dressings  takes  place,  the 
gauze  is  removed,  the  sutures  taken  out.  Outvvashing  of  the 
cavaty  with  sterile  salt  solution.  Under  a  few  dressings  the 
wound  is  healed  down  to  a  small  granulation  in  upper  angle  of 
the  wound,  and  therefore  the  patient,  with  the  injunction  to  have 
the  wound  dressed,  is  discharged  to  her  home  on  the  31.7. 
Marked  improvement. 

In  the  following  case  I  was  not  positive  zvJictJicr  a  stone  ivas 
impacted  in  the  clioledochns  ;  from  the  amnesis  one  was  obliged 
to  assume  it.  The  course  speaks  for  the  fact  that  in  spite  of  a 
revision  of  the  choledochus  a  small  concretion  lodged  here  was 
probably  overlooked. 

Wife  of  mining  councillor  K.,  62  years,  from  Giebichenstein, 
near  Halle.  Entered,  15.  11.  98.  Operation,  17.  11.  98.  Cys- 
tectomy.     Hepatopexy.      Discharged,  19.  12.  98. 

Amnesis. — Patient  comes  from  a  healthy  family  and  was  per- 
fectly healthy  until  4  years  ago,  when  she  suddenly  was  taken 
ill  with  violent  pains  in  the  upper  right  abdominal  region  and 
back.  Occasionally  there  occurred  similar  attacks  of  less  vio- 
lence ;  a  cure  in  Carlsbad  remained  without  results.  After  her 
return  home,  the  severe  attacks  associated  with  chills  increased 
in  frequency.  Internal  medication  is  said  to  have  brought  a 
cessation  of  the  suffering  for  two  years.  Six  weeks  ago  again 
very  painful  long-continued  attacks  associated  with  jaundice  of 
about  14  days'  duration.  Passage  of  stones  was  never  observed. 
Oil  treatment  and  others  were  unsuccessful.  On  the  day  before 
Mrs.  K.  entered  the  clinic  violent  pains,  the  urine  is  since  then 
again  dark.      Dr.  Urtel  advdsed  operation. 

Status  Praesens. — Medium-sized,  well-built,  well-nourished 
woman.     Sclera;  faintly  yellow-colored.     Organs  healthy.     Liver 


CLINICAL  AND  OPERATION  HISTORIES.  325 

not  enlarged,  in  the  region  of  the  gall-bladder  only  sensitive- 
ness to  pressure,  no  tumor  demonstrable.  Urine  free  from  albu- 
min and  sugar,  contains  traces  of  bile  pigment. 

Diagnosis. — Gallstones  in  a  contracted  gall-bladder.     Chole- 
dochus  stone  ? 

Operation. — Typical-longitudinal  incision  in  the  right  rectus 
abdominal  muscle  extending  from  the  curve  of  the  ribs  to  the 
height  of  the  navel.  In  the  course  of  the  operation  a  trans- 
verse incision  to  the  right,  which  began  i  cm.  above  the  navel, 
was  added.  Liver,  of  normal  appearance,  is  somewhat  mova- 
ble, yet  is  the  far  to  the  right,  high  up  under  the  liver  lying  con- 
tracted gall-bladder  only  with  difficulty  brought  in  view.  Dur- 
ing the  troublesome  attempt  to  separate  the  adhesions  which 
unite  the  gall-bladder  to  the  omentum  and  the  very  fat  peri- 
toneum of  the  posterior  abdominal  wall  the  fundus  of  the  gall- 
bladder is  loosened  from  the  liver,  and  it  is  therefore  sought  to 
further  separate  the  gall-bladder  from  the  liver.  It  is  on  account 
of  unusually  firm  connection  of  the  gall-bladder  with  the  liver 
only  possible  with  great  difficulty,  on  the  other  hand  the  suture 
of  the  gall-bladder  to  the  abdominal  wall  is  impossible  because 
of  the  great  depth  of  the  gall-bladder.  At  last  the  separation 
of  the  gall-bladder  succeeds  ;  now  the  ectomy  is  completed  in 
typical  manner,  the  cystic  us  double-ligatured  with  catgut  and 
oversewn  with  fine  catgut.  Tampon  of  the  pretty  briskly 
bleeding  liver  bed.  Choledochus  free  from  stones.  Closure  of 
the  abdominal  wound  with  through  and  through  interrupted 
silk  sutures  and  some  skin  sutures.  Exit  of  the  gauze  at  the  upper 
angle  of  the  wound. 

Course  afebrile  and  very  good.  On  the  30.  11.  change  of 
dressings,  removal  of  sutures  and  gauze.  Wound  in  the  best 
condition.  After  a  few  dressings  good  healing  of  wound.  Dis- 
charged on  the  19.  12.  98. 

Patient  has  at  home  again  colics  with  jaundice.  Does  a  stone 
still  lie  in  the  choledochus  ?  The  wound  which  was  healed  to 
a  fine  sinus,  again  breaks  open  without  that  slime  or  bile  escapes. 


326  GALLSTONE  DISEASE. 

Middle  of  March  curettage  of  it  and  tampon  with  sterile  gauze. 
Icterus  and  jaundice  did  not  again  occur.  According  to  recent 
information  the  patient  suffers  from  diabetes  (up  to  4  per  cent,), 
which  quickly  improves  under  diet. 

In  the  last  case  which  I  report  the  diagnosis  ''gallstones'^  was 
made  especially  from  the  amnesis.  TJie  result  of  examination 
was  almost  negative,  yet  I  found  pns  in  the  gall-bladder,  which 
moreover  had  assumed  a  real  hour-glass  form. 

Dr.  W.,  53^  years,  district  court  councillor,  from  Chemnitz. 
Entered,  29.  i.  99.  Operation,  31.  i.  99.  Cystectomy  (ampu- 
tation of  the  gall-bladder).      Discharged,  i.  3.  99.      Cured. 

Amnesis. — Parents  of  patient  died  of  old  age,  with  3  brothers 
there  is  no  known  stomach  or  gall-bladder  disease.  One  sister 
is  dead  from  disease  in  the  lower  abdomen.  Mr.  W.  was  in  his 
youth  healthy,  but  had  to  complain  somewhat  of  his  stomach 
(morning  vomiting,  years  ago  heartburn,  later  no  longer).  Six- 
teen years  ago  there  occurred  at  night  a  very  violent  cramp  of 
the  stomach  lasting  some  hours.  In  1880  the  patient  had 
typhoid.  Fourteen  years  ago  jaundice  of  some  14  days'  dura- 
tion appeared  without  previous  pains.  Six  or  eight  years  ago 
cramps  in  the  stomach  which  recurred  at  long  intervals.  The 
appetite  was  always  good.  A  cure  in  Kissingen  in  July,  1897, 
brought  about  a  ^  year  pause  in  the  attacks  of  cramps  in  the 
stomach.  On  the  i.  6.  98  violent  attack  of  cramp  in  the 
stomach  in  the  evening,  which  lasted  until  2.  6.  early  morning. 
Perhaps  this  attack  depended  upon  a  fall  from  his  bicycle  two 
days  before.  Slight  jaundice  is  said  to  have  been  present  with 
this  attack.  On  the  3.  and  4.  6.  another  attack;  the  physician 
made  out  an  enlargement  of  the  liver  of  high  degree  (acute 
cholecystitis  ?),  the  day  after  fever  of  about  a  week's  duration  ; 
during  this  recession  of  the  supposed  enlargement  of  the  liver, 
slight  jaundice,  stools  not  colorless,  constipated  for  3  days. 
24th  of  June  to  24th  of  July  cure  at  Carlsbad.  In  the  fourth 
week  colic  which  was  treated  medically  with  success.  Again 
marked  enlargement  of  the  Hver  without  fever.     After  cure  of  4 


CLINICAL  AND  OPERATION  HISTORIES.  327 

weeks  in  Marienbad  and  Elster.  Toward  the  end  of  August 
after  dinner  an  attack  with  severe  vomiting.  Enlargement  of 
the  Hver  and  fever  (cholecystitis  acuta).  8.  9.  98  an  attack 
which  lasted  about  24  hours,  and  was  associated  with  severe 
vomiting.  Fever  of  two  days'  duration,  with  enlargement  of 
liver.  Afterwards  from  the  middle  of  September  until  the  end 
of  October  in  a  sanatorium  ;  excellent  condition.  Journey  to 
Vienna  and  Abbazia ;  here  an  attack  after  a  wagon  ride  on  a 
bad  road,  violent  vomiting.  Enlargement  of  liver  with  dyspnoea, 
no  fever.  Slight  attack  of  pain  in  Chemnitz  on  30.  11.  Attack 
on  the  30.  12.  14.  I.  likewise  an  attack  after  travelling  on 
electric  road  ;  attack  lasted  24  hours.  The  pains  in  the  last  3 
attacks  were  less  and  were  situated  as  formerly  in  the  pit  of  the 
stomach,  no  vomiting.  The  appetite  in  the  interval  was  very 
good  with  strict  diet  (avoidance  of  fats,  acids,  soups,  etc.). 
Loss  of  flesh  occurred  (approximately  it  amounts  to  12  pounds). 
Present  bodily  weight  82^  kilo. 

Status  Prsesens. — Large,  slender,  well-nourished  man.  Or- 
gans normal  except  for  arteriosclerosis.  Urine  normal.  Liver 
not  enlarged,  in  the  region  of  the  gall-bladder  increased  resist- 
ance, no  palpable  tumor. 

Diagnosis. — In  consequence  of  frequent  inflammatory  attacks 
contracted  gall-bladder  with  adhesions.  In  the  gall-bladder 
stones.      Cysticus  free. 

Operation. — Longitudinal  incision  in  the  right  rectus  abdom. 
mus.  extending  upwards  along  the  ribs  to  the  xyphoid  process. 
Gall-bladder  and  lower  liver  border  extensively  adherent  to  the 
omentum.  Separation.  Gall-bladder  is  of  hour-glass  form,  the 
part  lying  toward  the  fundus  the  size  of  a  pigeon's  egg,  contains 
thin  pus.  Between  this  part  and  that  lying  toward  the  chole- 
dochus  there  is  an  impermeable  stricture.  The  rest  of  the  gall- 
bladder contains  clear  bile  and  a  large  stone.  Ectomy  of  the 
gall-bladder.  Tamponade.  Suture  of  the  abdominal  wound. 
Duration  of  the  operation,  i  hour. 

Course  very  good.    No  fever.    First  change  of  dressings  on  the 


328  GALLSTONE  DLSEASE. 

14th  day.  Wound  in  good  condition.  Removal  of  stitches  and 
tampon.  Patient  gets  out  of  bed  the  i6th  day  and  is  extraor- 
dinarily jolly  so  that  he  can  be  discharged  on  the  i.  3.  99. 
After  cure  in  Carlsbad. 

Remarks. — I  have  often  enough  seen  hour-glass  formed  gall- 
bladders, but  not  until  then  that  form  of  anomaly.  (In  fundus 
pus,  then  stricture,  in  neck  clear  bile,  with  patent  cysticus  and 
stone.)  The  stricture  is  the  consequence  of  an  ulcer.  The  in- 
fected contents  remain,  yet  the  patient  had  so  little  distress.  He 
lived  in  constant  danger  of  life,  since  he  carried  an  explosive 
about  with  him.  It  was  well  that  he  permitted  an  operation 
upon  himself 

With  this  I  close  my  introduction  to  the  learning  of  the  diag- 
nosis of  the  separate  forms  of  cholelithiasis,  and  I  cherish  the 
hope  that  my  work  may  be  an  adviser  and  a  pathfinder  which 
will  be  not  unwelcome  to  the  practitioner  in  this  very  difficult 
field  and  in  its  devious  ways  and  uneven  paths. 


APPENDIX. 


At  the  end  of  March  I  had  disposed  of  409  gallstone  lapa- 
rotomies ;  to-day,  on  the  i6th  of  May,  427  of  this  sort  of  opera- 
tion. TJiat  is  in  46  days  my  material  had  increased  by  18  lapa- 
rotomies for  cholelithiasis.  The  patients,  who  came  to  the  clinic 
from  Halberstadt  and  the  adjoining  country,  represented  for  the 
most  part  simple  and  easily  diagnosticated  cases  (acute  chole- 
cystitis, etc.),  whilst  the  patients  who  came  from  a  distance  col- 
lectively furnished  the  most  complicated  conditions.  Among 
the  18  laparotomies  there  were  alone  8  choledochotomies 
(among  them  3  cases  of  hepaticus  drainage) ;  only  one  pursued  a 
fatal  course,  owing  to  carcinomatous  stricture  of  the  hepatic 
duct.  The  patient,  intensely  icteric,  succumbed  to  a  pneumonia. 
A  second  fatality  happened  with  a  patient  likewise  the  subject  of 
carcinoma  who  died  of  cholaemia.  The  remaining  patients  re- 
covered or  are  on  the  road  to  cure.  In  all  I  have  had  the  oppor- 
tunity to  examine  in  the  last  lyi  months  25  gallstone  cases. 
Five  I  sent  to  Carlsbad,  since  they  showed  only  mild  inflam- 
matory processes  in  the  gall-bladder  ;  2  would  not  accept  the  pro- 
posal of  an  operation  although  they  suffered  from  dropsy  and 
empyaema  of  the  gall-bladder  ;  the  remaining  18  were  operated 
on.  At  this  moment  there  are  lying  in  my  clinic  13  patients  who 
have  undergone  operations  for  gallstones.  Before  I  proceed  to 
the  giving  of  those  clinical  histories  which  are  of  special  interest 
in  relation  to  diagnosis,  I  would  like  to  be  permitted  some  re- 
marks concerning  inflammatory  icterus  and  the  infection  of  the 

system  of  bile  ducts. 

j8  (  329  ) 


330  GALLSTONE  DISEASE. 

Riedel  at  the  Diisseldorf  meeting  of  the  NaturaHsts  gave  a 
lecture,  which  he  has  pubhshed  in  the  Metteil.  aus  den  Grenz- 
gebieten  der  Med.  u.  Chir.  IV.,  Bd.  IV.  Heft  p.  565.  (At  the  de- 
bate concerning  gallstones  in  Diisseldorf,  with  remarks  concern- 
ing the  insidious  infection  of  the  gall-duct  system  after  the  pas- 
sage of  stones  per  vias  naturales.)  In  this  lecture  Riedel  cites 
several  demonstrative  cases  of  "  inflammatory  jaundice."  In  my 
last  work  in  the  Archiv  von  Langenbeck,  58  Bd.  Heft  3,  I  was 
already  able  to  make  the  following  remarks  upon  inflammatory 
jaundice  wuth  reference  to  Riedel's  composition  *'  On  the  pathol- 
ogy and  diagnosis  of  the  gallstone  colic  attack."  (Mitteil.  aus 
den  Grenzgeb.  der  Med.  u.  Chir.  III.,  Bd.  2.  Heft  p.   167.) 

''Riedel  has  seen  inflammatory  jaundice  in  10  per  cent,  of 
the  cases  of  cholecystitis  serosa,  the  existence  of  which  he  will 
prove  by  several  cases.  To  us  also  the  doctrine  of  inflammatory 
jaundice  is  very  welcome  and  plausible,  yet  we  may  assert  that 
the  absolute  proof  that  one  has  to  do  with  a  case  of  inflammatory 
jaundice  is  impossible.  Whoever  will  prove  this,  must  himself 
accurately  examine  every  stool  for  stones  at  least  for  four  weeks, 
and  if  he  finds  none,  although  jaundice  was  there  present,  he 
cannot  then  always  assert  that  the  jaundice  w^as  of  inflamma- 
tory origin,  since  as  a  matter  of  experience  the  expelled  stones 
may  be  dissolved  in  the  intestine.  The  case  which  Riedel  cites 
(No.  58,  S.  198)  by  no  means  proves  the  existence  of  inflamma- 
tory jaundice  with  certainty.  We  have  observed  that  despite  of 
a  large  obstructing  stone  in  the  neck  of  the  gall-bladder  small 
stones  may  lodge  in  the  choledochus,  may  pass  without  giving 
rise  to  the  slightest  distress.  The  jaundice  in  such  cases  is  in  a 
certain  measure  also  in  so  far  of  lithogenous  nature,  as  the 
large  obstructing  stone  so  presses  upon  the  choledochus  that  its 
passage  is  in  part  obstructed.  Then  one  does  not  have  to  do 
witii  a  case  of  inflammatory  jaundice  in  Riedel's  sense,  but  with 
an  indirect  lithogenous  jaundice.  In  Riedel's  case  No.  162  we 
believe  that  during  the  lithotripsy  fragments  of  stone  had  been 
discharged   into   the    choledochus,   therefore   the    occurrence   of 


APPENDIX. 


331 


fever  and  the  escape  of  very  considerable  bile.  Riedel  says 
nothing  of  the  examination  of  the  stools,  yet  we  assume  that  they 
have  been  accurately  examined.  But  even  if  no  stone  fragments 
were  found,  this  case  is  then  no  '  positive '  case,  but  an  ex- 
tremely *  doubtful '  case  of  inflammatory  jaundice." 

In  the  most  recent  publications  Riedel  seeks  to  bring  his 
"darling  child,"  as  he  styles  inflammatory  jaundice,  to  the 
widest  possible  recognition  ;  in  doing  this  it  befalls  him  as 
almost  every  father  ;  in  his  blind  love  he  overlooks  the  weakness 
and  defects  of  his  child,  and  it  is  necessary  for  another  to  point 
out  to  him  that  he  favors  his  child  too  much. 

Cases  Nos.  234,  247  and  251  of  his  statistics  have  not  had  in 
my  opinion  inflammatory,  but  positively  real  lithogenous  icterus, 
and  the  proofs  which  he  brings  forward  for  the  "inflammatory" 
form  are  according  to  my  experience  not  sound.  Riedel  relies 
far  too  much  upon  the  proof  of  stones  in  the  stools  ;  if  none  were 
found  then  even  "inflammatory"  jaundice  existed.  That  fre- 
quently stones  dissolve  in  the  intestine  I  have  already  empha- 
sized. Then  he  will  assume  the  intactness  of  the  cysticus  and 
choledochus  for  the  reason  that  the  two  positively  have  never 
been  touched  by  the  passing  of  stones.  Now  I  open  the  bile 
ducts  so  freely  and  cut  them  open  surely  oftener  than  Riedel, 
even  in  those  cases  in  which  I  imagine  only  stones,  that  I  may 
be  permitted  a  judgment  concerning  the  condition  of  the  cysticus 
and  choledochus  and  their  changes  from  passing  stones.  Stones 
may  pass  the  cysticus  and  lie  in  the  choledochus  and  neverthe- 
less the  ducts  from  without  look  "  uncommonly  delicate  and  thin- 
walled,"  so  that  one  cannot  believe  that  a  stone  has  here  pur- 
sued its  disturbance.  The  large  occluding  stone  in  the  cysticus 
does  not  prove  by  any  means,  as  I  have  already  emphasized 
above,  that  small  stones  do  not  still  lie  in  the  choledochus.  I 
have  observed  several  cases  in  which  in  spite  of  a  large  obstruct- 
ing stone  in  the  cysticus  small  stones  wandered  about  in  the 
choledochus,  which  from  witJioiit  looked  absolutely  nojniial.  In 
these  cases  the  surgeon  who  does  not  open  the  bile  ducts  will 


332  GALLSTONE  DISEASE. 

diagnosticate  inflammatory  jaundice,  although  however  real 
lithogenous  jaundice  exists.  The  cystic  duct  of  course  dilates, 
if  a  stone  passes  through,  but  it  does  not  at  all  necessarily  suffer 
through  the  stone  which  passes  through,  and  it  will  again  assume 
its  original  form  and  shape  if  the  concretion  has  not  too  long 
tarried  in  it.  The  "  inflammatory  jaundice  "  has  become  in  its 
real  existence  for  me  very  doubtful  the  more  I  have  practiced 
the  thorough  exposure  of  the  bile  ducts  ;  Riedel's  darling  child 
is  a  being  of  weak  frame,  and  I  would  give  the  practitioner  the 
advice  which  I  have  already  expressed  in  the  first  part  of  this 
book.  If  jaundice  appears,  then  we  ought  to  recognize  that  the 
cholelithiasis  has  lost  its  local  character,  that  the  disease  is  no 
longer  limited  to  the  gall-bladder,  but  has  dragged  the  liver  into 
participation  in  the  disease  process.  The  real  lithogenous  icterus 
is  for  me  a  fact ;  the  inflammatory  may  be  present,  but  it  is  not  to 
be  clinically  diagnosticated.  But  I  indeed  believe  that  the  func- 
tional icterus  in  the  sense  of  Pick  and  of  Liebermeister  exists  and 
oftener  occurs  with  gallstone  disease — perhaps  also  with  stones 
in  the  gall-bladder  only — than  one  imagines. 

Moreover,  Riedel  again  gives  in  his  most  recent  contribution 
(Grenzgebiet.  der  Med.  u.  Chir.  IV.,  Bd.  IV.  Heft),  3  clinical  his- 
tories (Nos.  201,  239,  245),  which  present  very  striking,  but  to  me 
at  least  unknown  facts.  They  concern  patients  by  whom  a  short 
or  longer  time  before  a  stone  had  passed  per  vias  naturales  ; 
patients  who  since  this  attack  felt  suffering  and  weak,  but 
nevertheless  came  in  a  condition  for  operation,  such  that  one 
could  not  foresee  severe  complications.  Since  no  fever  existed, 
the  liver  was  not  enlarged,  and  the  icterus  already  for  a  long 
time  had  disappeared,  one  could  not  suspect  that  a  severe  infec- 
tion of  the  system  of  bile  ducts  existed.  With  2  patients  the 
simple  cystostomy  was  carried  out.  With  the  third  the  gall- 
bladder was  extirpated  ;  in  all  3  cases  the  gall-bladder  contained 
muddy,  positively  infectious  bile.  The  patients  died,  since  the 
infection  extended  into  the  bile-duct  system,  and  Riedel  assumed 
that  this  infection  had  not  arisen  during  the  operation,  but  already 
had  existed  a  long  time,  at  least  since  the  last  attack. 


APPENDIX.  333 

I  have  no  reason  to  throw  doubt  upon  Riedel's  observations 
and  deductions,  but  I  would  emphasize  the  fact  that  I  person- 
ally have  never  seen  ajiytJdng  like  thejfi,  nevertheless  my  mate- 
rial is  not  less  than  that  of  Riedel,  and  I  also  receive  cases  re- 
ferred to  me  which  leave  nothing  wanting  in  their  sufferings  and 
complications. 

When  I  had  thoroughly  studied  these  3  cases  I  asked  my 
assistants — one  had  assisted  me  in  about  200  gallstone  opera- 
tions— whether  they  could  recall  similar  cases  from  my  ma- 
terial. To  them  also  was  Riedel's  observation  completely  new. 
Up  till  the  present  I  Jiave  never  lost  a  patient  from  infection  of 
the  bile-duct  system  after  a  simple  cystostomy  with  patent  chole- 
dochus.  According  to  my  opinion  the  cystostomy  is  and  re- 
mains with  patients  who  at  the  moment  of  operation  have  no 
fever,  no  icterus,  no  enlargement  of  the  liver,  an  operation  very 
free  from  danger.  Now  let  one  imagine  that  after  this  operation, 
although  the  choledochus  was  positively  free  from  stones, 
shortly  before  no  fever  existed,  good  appetite  and  ''  cheerful 
disposition"  were  present,  several  patients  die.  "Would  they 
have  died  if  they  had  not  been  operated  upon  ?"  This  question 
must  obtrude  itself  upon  each  one.  Riedel  answers  in  the 
affirmative  :  '*  That  these  cases  died  with  severely  infected  bile- 
duct  system,  of  this  indeed  there  is  no  doubt."  I  have  indeed  not 
seen  Riedel's  cases,  and  I  have  no  intention  to  criticize  the  misfor- 
tunes of  another  cHnic,  but  I  must  point  out  that  I  have  obtained 
very  good  results  with  the  treatment  of  severe  infections  of  the 
bile-duct  system  recently,  since  I  do  not  fear  to  add  to  the  re- 
moval of  the  stone- containing  gall-bladder  the  drainage  of  the 
hepaticus.  According  to  the  contribution  of  Riedel  there  was 
indeed  no  indication  in  his  cases  for  drainage  of  the  hepaticus, 
therefore  my  results  would  have  been  also  no  different  than 
those  of  Riedel.  But  the  cases  in  which  the  drainage  of  the 
hepaticus  was  appropriate,  in  which  muddy,  stinking,  severely 
infected  bile  for  days  escaped  from  the  bile-duct  system,  I  have 
seen  frequently  enough,  and  can  only  say  that  in  this  method  of 


334  GALLSTONE  DISEASE. 

treatment  a  great  advance  has  been  made  in  severe  cholangitis. 
Riedel  is  also  in  this  respect  very  pessimistic  ;  perhaps  on  this 
account  since  he  has  not  tried  this  method  of  operation  an- 
nounced by  me  at  the  Brunswick  Meeting  of  Naturalists  ;  yet 
he  is  wrong  when  he  asserts  "  The  patients  with  severe  infected 
bile-duct  system,  on  the  contrary,  no  mortal  can  save,"  or  as  he 
in  another  place  says  :  "  The  patients  severely  infected  with 
staphylo-  or  streptococci  or  with  bacterium  coli  will  die ;  it 
makes  no  difference  whether  one  operates  on  them  or  not." 
That  is  now  no  longer  true,  as  I  can  say  to  calm  many  alarmed 
physicians. 

Of  perialienitis  infectiosa  choledochi — so  could  I  write  in  the 
Archiv  fiir  klin.  Chirurgie — even  without  operation  for  a  long 
time,  yet  all  men  do  not  die.  We  have  seen  patients  with  intense 
jaundice,  temperature  to  40.0°  C,  chills,  very  painful  liver,  who 
appeared  so  ill  to  us  that  we  dared  not  undertake  an  operation  ; 
and  these  patients  pulled  through.  It  was  no  perialienitis  serosa, 
but  a  severe  infection  which  positively  existed,  without  that  the 
bacteriological  proof  could  be  given. 

And  we  have  operated  upon  cases  which  from  the  first  ap- 
peared hopeless,  in  which  stinking,  muddy  bile  escaped  from  the 
choledochus  and  yet  the  patients  recovered.  Indeed,  if  one  in  such 
cases  sutures  the  incision  of  the  choledochus,  it  is  then  very  pos- 
sible that  the  cholangitis  makes  greater  advances,  since  we  here 
run  counter  to  the  good  principle  of  open  wound  treatment.  How- 
ever, if  one  does  not  suture,  but  carries  out  hepaticus  drainage, 
then  one  may  well  suppress  the  infectious  process  in  the  chole- 
dochus and  the  large  branches  of  the  hepaticus,  if  even  we  do 
not  also  imagine  that  we  are  able  to  set  aside  the  diffuse  infec- 
tious cholangitis  of  the  smallest  bile  ducts.  Here  the  relations 
are  the  same  as  in  phlegmon  in  the  arm  ;  an  ordinary  incision 
suffices  when  the  process  is  still  a  local  one,  it  will  be  without 
result  if  metastases  have  already  taken  place  in  the  body.  If 
Riedel  employs  the  hepaticus  drainage,  he  will  certainly  be 
cured  of  his  pessimism  regarding  perialienitis  infectiosa.    Riedel' s 


APPENDIX. 


335 


case  No.  i6i  (p.  229)  terminated  fatally  in  my  opinion  on  this 
account,  since  the  bile  was  infected  and  the  choledochus  suture 
gave  way.  We  have  observed  4-5  times  this  giving  way  of  the 
suture  without  a  single  patient  dying,  but  we  do  not  conclude 
from  this  fact  that  the  bile  was  infected,  but  we  seek  the  cause 
in  a  technically  incomplete  suture,  in  a  false  indication  for  chole- 
dochotomy. 

One  case  was  very  instructive  in  this  respect.  Patient,  the 
mother  of  a  physician  from  Miinster  i.  W.,  was  operated  on  by 
choledochotomy  and  a  suture  was  applied.  There  occurred 
high  fever  (to  39.5°).  Acceleration  of  the  pulse  (up  to  140 
beats  a  minute).  Vomiting,  intense  icterus  ;  in  a  word  all  the 
symptoms  of  perialienitis  infectiosa.  One  day  the  suture  gave 
way,  the  bile  stank  horribly — but  the  patient  pulled  through, 
since  she  had  been  tamponed  and  the  bile  could  escape  out- 
wards. A  quantity  of  stone  fragments  was  discharged.  Had 
Riedel  tamponed  in  his  case  the  patient  then  surely  would  not 
have  died.  Also  in  my  other  cases  muddy  bile  escaped  from 
the  ruptured  suture  in  the  choledochus,  but  the  patients  by  no 
means  died,  since  the  bile  could  escape  outwards  through  the 
gauze. 

The  one-sided  choice  of  operation  upon  the  choledochus,  as 
is  shown  by  the  choledochotomy  ivith  siiture  in  all  cases,  is  wrong. 
There  is  here  repeated  on  the  choledochus  the  same  occurrence 
which  has  taken  place  with  the  operations  on  the  gall-bladder. 
At  first  one  did  cystostomies  exclusively,  then  almost  only  cys- 
tectomies and  cystendyses  ;  now  one  governs  himself  according  to 
the  pathological  condition.  In  choledochotomy  many  suture  as 
a  matter  of  principle  without  tamponing.  Whoever  in  chole- 
dochotomy, regarding  the  question  of  suturing  or  draining,  guides 
himself  solely  by  the  course  before  operation  or  by  the  assumed 
pathological  condition,  will  do  the  right  thing.  One  should 
always  tampon  but  never  suture  if  the  bile  is  muddy  and  cho- 
langitic  symptoms  have  preceded. 

A  cystendysis  is  possible  when  the  cystic  duct  is  free  and  the 


336  GALLSTONE  DISEASE.  ' 

walls  of  the  gall-bladder  are  suited  to  suture.  The  same  is  the 
case  with  choledochotomy  ;  the  papilla  must  be  free,  the  walls 
of  the  duct  must  not  be  pathologically  changed.  But  a  cysten- 
dysis  should  always  be  supplanted  by  a  cystostomy — indeed  the 
latter  is  far  less  dangerous.  A  choledochotomy  with  suture 
may  give  place  to  a  choledochotomy  without  suture,  but  the 
latter  is  more  dangerous  than  the  former.  We  do  not  suture 
only  then  when,  by  reason  of  the  changes  in  the  bile  and  the 
walls  of  the  choledochus,  and  finally  by  the  deep,  almost  inac- 
cessible position  of  the  duct,  we  are  constrained  to  it. 

Every  one  is  impressed  in  Riedel's  publications  by  the  au- 
thor's love  of  truth,  which  even  does  not  palliate  or  gloss  over  his 
failures.  In  the  treatment  of  cholelithiasis  we  must  learn  from 
the  failures  that  it  is  not  advisable  to  dawdle  until  the  stones 
reach  the  choledochus,  since  we  now  know  that  even  with  a 
successful  attack,  that  is  with  the  passage  of  stones  through  the 
papilla  of  the  duodenum  an  insidious  infection  of  the  system  of 
the  bile  ducts  can  develop,  which  most  seriously  threatens  the 
life  of  the  patient.  We  should,  if  we  would  take  to  heart  the  ob- 
servations of  Riedel,  operate  upon  every  case.  That  would 
indeed  lead  us  too  far.  The  acute  obstruction  of  the  chole- 
dochus I  leave  to  internal  treatment,  but  upon  suspicion  of  in- 
fection of  the  system  of  bile  ducts  (suffering  and  emaciation  of 
the  patient)  I  would  advise  the  addition  to  the  cystostomy  or 
ectomy  of  drainage  of  the  hepaticus.  Very  recently  I  have 
observed  that  this  operation  correctly  executed  does  not  bring 
actual  danger  to  the  patient.  Perhaps  it  is  in  such  cases  advis- 
able first  to  inaugurate  a  Carlsbad  cure,  from  which  I  expect  a 
great  deal  in  overcoming  the  inflammatory  processes  in  the  bile 
ducts  ;  yet  one  must  reflect  in  so  doing  that  thus  considerable 
valuable  time  passes,  and  in  the  quite  possible  failure  of  a  cure 
in  Carlsbad  the  proper  time  for  operation  may  be  let  slip. 

It  will  impress  many  that  here  in  a  book  written  only  for 
practitioners  I  treat  too  minutely  those  questions  in  dispute  con- 
cerning  inflammatory   jaundice    and    infection   of  the   bile-duct 


APPENDIX. 


337 


system.  I  think,  however,  that  exactly  for  the  practicing  physi- 
cian it  is  of  the  greatest  importance  to  know  that  the  diagnosis 
of  inflammatory  jaundice  cannot  be  positively  made.  "  In  inflam- 
matory jaundice  an  operation  is  always  indicated  ;  indeed  there 
are  no  stones  present  in  the  choledochus,"  is  the  view  of  the 
physician  who  recognizes  the  positive  existence  of  the  inflam- 
matory jaundice.  If  then  a  cystostomy  is  executed,  then  will 
the  stones  in  the  choledochus,  since  lithogenous  icterus  exists, 
be  easily  overlooked,  and  it  will  be  said  everywhere  the  opera- 
tion is  a  failure,  the  stones  grow  again,  whilst  in  fact  stones  were 
left  since  the  operation  was  not  done  at  the  proper  time.  In 
acutely  occurring  jaundice  one  should  consider  very  carefidly 
whether  one  shoidd  operate  at  all.  I  can  only  advise  the  practicing 
physician  to  be  very  carefid  in  recommending  operation  in  such  cases, 
a7id  oidy  then  to  have  it  done  ivhen  fever  occurs,  severe  symptoms 
of  cholangitis  become  evident,  the  appetite  fails  and  failure  of 
strength  occurs. 

Of  the  1 8  cases  treated  by  operation  I  will  report  13  which 
with  reference  to  diagnosis  are  of  value,  and  whose  cure  is  al- 
ready so  far  advanced  that  there  can  scarcely  be  a  doubt  of  a 
final  successful  issue. 

With  the  following  patient  we  had  to  do  with  a  relatively  early 
case.      The  operation  zvas  indicated  by  social  reasons. 

M.  T.,  housekeeper,  22  years,  from  Halberstadt.  Entered, 
29.  4.  99.  Oper.,  2.  5.  99.  Cystectomy.  Hepaticotomy.  Still 
under  treatment. 

Amnesis. — Family  history  without  importance.  Patient  had 
as  a  12  year  old  child  suffered  6  weeks  from  jaundice,  other- 
wise she  has  never  been  really  ill.  Whitsunday,  1898,  the 
patient  for  the  first  time  was  taken  with  cramps  in  the  stomach, 
violent  piercing  pains,  which  radiated  toward  the  back  and  feet, 
and  were  attended  by  violent  eructations  and  great  weakness  ; 
this  attack  lasted  about  4  hours  (no  icterus,  no  fever).  The 
second  attack  occurred  again  in  the  best  of  health,  at  the  end  of 
October  of  the  same  year,   and    showed  the  same    symptoms. 


338  GALLSTONE  DISEASE. 

Dr.  Crohn  of  Halberstadt  diagnosticated  gallstones  ;  morphine 
controlled  the  pains,  a  Carlsbad  cure  carried  out  afterwards  at 
home  was  apparently  of  good  success  ;  at  all  events  the  patient 
afterwards  felt  perfectly  well  until  March  of  this  year.  The  third 
attack  was  like  the  first  two,  only  the  pains  lasted,  with  short 
intervals,  3  days,  and  yielded  only  to  morphine.  Afterwards  the 
patient  also  suffered  frequently  from  trouble  in  the  stomach,  loss 
of  appetite,  pressing  pain  after  eating,  and  felt  continually  weak 
and  ill.  The  fourth  attack  occurred  on  the  28.  4.  99,  and  was 
in  no  respect  different  from  the  others.  Dr.  Crohn  advised 
operation. 

Icterus  is  said  to  have  occurred  neither  during  nor  after  the 
attacks  ;  fever  is  said  never  to  have  been  present. 

Status  Praesens. — Very  powerful,  well-nourished  girl.  No 
icterus,  no  enlargement  of  the  liver,  no  tumor.  Only  sensi- 
tiveness to  pressure  in  the  region  of  the  gall-bladder.  Urine 
normal.      Heart  and  lungs  normal. 

Diagnosis. — Cholecystitis  recidiva.  At  present  cystic  duct 
free. 

Operation,  2.  5.  99.  Longitudinal  incision  in  the  right 
rectus  abdominalis  muscles.  The  gall-bladder  extends  about 
5  cm.  beyond  the  lower  border  of  the  not  enlarged  liver.  Be- 
tween the  cysticus  and  duodenum,  or  choledochus,  extensive 
adhesions.  Just  as  soon  as  these  were  separated  the  gall-blad- 
der collapses.  In  the  cysticus  a  small  cholestearin  stone.  Ex- 
cision of  the  gall-bladder.  In  the  hepaticus  one  feels  a  hard 
spot.  In  order  to  determine  what  exists  the  hepaticus  is  incised 
about  I  ^  cm.  above  the  entrance  of  the  cysticus.  Sounding 
of  the  hepaticus  and  choledochus  discloses  normal  relations  ;  no 
stone.  Suture  of  the  hepaticus  and  cysticus  transverse  incision 
with  catgut.  Tamponade  with  sterile  gauze  (foramen  of  Win- 
slow  and  hepaticus  suture).  Suture  of  the  abdominal  wound 
with  through  and  through  silk  sutures.  Duration  of  operation, 
I  i^  hours.      Good  chloroform  anaesthesia. 

Course. — On  the  evening  of  the  day  of  operation  some  bile  in 


APPENDIX. 


339 


the  dressings.  On  the  next  day  change  of  dressings  without  re- 
moval of  the  tampon.  Pulse,  72  ;  temperature,  37.1°  C.  No 
vomiting.  Further  condition  excellent.  In  the  dressings  no 
more  bile  since  the  16.  5.  Removal  of  the  tampon.  No  pain. 
Good  appetite. 

Remarks. — Here  we  had  to  do  with  a  relatively  fresh  case. 
Until  then  the  cholecystitis  had  not  succeeded  in  pushing  the 
small  stone  into  the  cystic  duct,  but  't  was  up  till  then  2  cm. 
distant  from  the  choledochus.  Might  not  the  stone  some  time 
have  got  as  far  ?  Might  not  it  have  increased  in  size  in  the  cystic 
duct?  At  all  events  the  patient  had  had  enough  of  grievous 
pain  ;  she  wished  as  servant  to  earn  her  bread  and  was,  by  fre- 
quently getting  ill,  hindered  in  this.  At  the  time  the  inflamma- 
tion was  extinguished.  The  bile  showed  itself  sterile.  The 
opening  of  the  hepaticus  was  unnecessary,  but  one  cannot  be  too 
careful  in  his  judgment  whether  all  stones  are  removed.  Better 
open  the  common  duct  once  too  often  than  once  too  seldom. 
With  a  good  technique  it  does  no  harm.  Here  we  had  to  do 
with  a  sturdy  person,  whose  choledochus  was  very  accessible 
and  with  whom  the  bile  removed  from  the  gall-bladder  was  as 
clear  as  gold.  The  incision  in  the  hepaticus  had  lengthened  the 
operation  perhaps  half  an  hour,  but  with  the  excellent  view 
which  one  had  of  the  ligamentum  hepatico-duodenale,  the  in- 
cision complicated  the  ectomy  but  very  little.  The  gall  ducts 
are  not  always  so  easily  exposed,  as  in  this  case,  especially  then, 
not,  when  many  adhesions  exist  in  the  depths  and  the  inflam- 
mation has  already  involved  the  ligamentum  hepatico-duodenale. 
If  one  comes  early  to  operation,  then  it  is  usually  easy  to  deter- 
mine that  all  the  stones  are  out  of  the  gall-bladder  and  cysticus, 
and  that  in  the  choledochus  and  hepaticus  no  others  exist.  /;/ 
early  operation  tJic  experienced  surgeon  leaves  no  stones  behind, 
only  then  can  it  happen  to  him,  when  he  is  obliged  to  appeal  late 
to  the  knife.  The  reproach  does  not  belong  to  us  that  stones  re- 
main behind,  but  to  the  patients  who  are  afraid  of  an  operation 
and  to  the  physician  who  puts  it  off  too  long. 


340  GALLSTONE  DISEASE. 

/;/  the  folloiving  case  we  had  to  do  with  acute  obstruction  of  the 
clioledochiis : 

Mrs.  J.  H.,  24  years,  hedge-laborer's  wife,  from  AUrode.  En- 
tered, 12.  5.  99.  Oper.,  13.  5.  99.  Ectomy,  hepaticus  drain- 
age.    Still  under  treatment. 

Amnesis. — Family  history  and  previous  life  of  no  conse- 
quence. Patient  has  2  healthy  children  ;  the  confinements  were 
normal,  last  about  3  years  ago.  Two  years  ago  in  complete 
health  the  patient  was  attacked  suddenly  with  extraordinarily 
violent  cramp-like  pains  in  the  region  of  the  liver,  which  radiated 
to  the  breast  and  back.  Already  at  that  time  the  attending 
physician  diagnosticated  gallstones.  These  attacks  recurred  now 
in  intervals  of  2-4  weeks  with  varying  violence  ;  with  them  it  is 
said  there  was  never  icterus,  nor  fever,  rarely  vomiting.  Since 
Easter  of  this  year  the  patient  has  been  constantly  ill,  feeling  of 
pressure  in  the  gall-bladder  and  stomach  regions,  loss  of  appe- 
tite, frequent  eructations,  constipation  tortured  her  continually  ; 
with  this  the  attacks  of  cramp  increased  and  have  occurred  re- 
cently almost  every  other  day.  Formerly  the  patient  had 
already  noticed  after  each  attack  a  tumor  in  the  region  of  the 
gall-bladder,  which  gradually  disappeared  again.  Since  about 
Easter,  however,  the  tumor  has  no  longer  diminished,  but  rather 
gradually  increased.  In  the  last  few  weeks  often  fever  in  the 
evening,  sometimes  chills,  with  them  no  icterus  ;  but  marked 
emaciation  on  account  of  marked  participation  of  her  general 
health  and  great  digestive  trouble,  which  have  constantly  become 
worse.  In  the  beginning  the  patient  carried  out  at  home  with- 
out success  a  Carlsbad  cure,  besides  she  has  been  treated  for  the 
most  part  internally  with  purgatives  and  narcotics. 

Status  Praesens. — Small,  graceful,  very  thin  woman,  with  a 
very  suffering  expression  of  face.  In  the  gall-bladder  region 
one  feels  a  very  sensitive  to  pressure  and  pretty  hard  round 
tumor  which  extends  downwards  to  the  level  of  the  navel,  has 
a  (average)  length  of  about  12  cm.,  a  breadth  of  about  8-9  cm., 
and  can  be  pushed  a  little  toward  each   side.     Above — as  per- 


APPENDIX.  341 

cussion  and  palpation  disclose — the  tumor  passes  broadly  into 
the  liver,  backward  it  cannot  be  moved.  The  liver  extends  be- 
yond the  curvature  of  the  ribs  in  the  nipple  line  2  good  finger- 
breadths,  and  is  not  enlarged  above.  With  it  there  exists  a 
strikingly  marked  dilatation  of  the  stomach,  which  extends  be- 
yond the  height  of  the  navel  a  finger-breadth  ;  motor  functions 
of  the  stomach  very  much  lengthened  ;  chemical  unchanged. 

Diagnosis. — Empyema  of  stone  containing  gall-bladder,  ad- 
hesions to  the  pylorus,  dilatation  of  the  stomach.  On  the  day 
of  entrance  violent  colic,  icterus.  Stones  have  entered  the  chole- 
dochus. 

Operation,  13.  5.  99.  Longitudinal  incision  in  the  right 
rectus  abdominal  muscle.  Gall-bladder  and  liver  large.  Gall- 
bladder adherent  to  the  pylorus  and  duodenum.  Separation. 
Gall-bladder  separated  from  the  liver.  Cysticus  divided. 
Through  the  cysticus  from  the  choledochus  escapes  muddy, 
serous  fluid.  Division  of  the  cystic  and  common  ducts.  Head 
of  pancreas  thickened.  In  the  retroduodenal  part  of  the  chole- 
dochus a  cherrystone-sized  stone.  Extraction.  Since  muddy, 
serous  fluid  escapes  from  the  hepaticus,  hepaticus  drainage. 
Tamponade.  Closure  of  the  abdominal  wound  after  the  intro- 
duction of  a  tube  into  the  hepaticus.  Suture  of  the  cysticus  and 
of  the  incision  in  the  choledochus  with  fine  catgut.  Duration  of 
the  operation,  i  hour. 

Remarks. — The  stone  first  entered  the  choledochus  on  the 
day  before  the  operation.  In  it  the  same  muddy,  serous  fluid  as. 
in  the  gall-bladder.  The  case  is  a  proof  that  the  colics  depend 
upon  inflammatory  processes.  The  bile  was  caught  and  will  be 
bacteriologically  examined.  The  adhesive  peritonitis  on  the 
peritoneum  was  of  recent  date.  The  separation  was  easy,  there 
was  no  reason  for  a  pyloroplasty  or  a  gastroenterostomy.  The 
course  was  afebrile  heretofore  ;  from  the  tube  escaped  daily 
about  400-500  gr.  of  bile,  without  the  patient  having  the  slight- 
est distress.      In  the  bile  bacterium  coli  and  streptococci. 

In  the  foil oiving  case  I  saw  a  very  peculiar  form  of  empyema : 


342  GALLSTONE  DISEASE. 

Mrs.  K.,  38  years,  wife  of  a  manufacturer,  from  Nordhausen. 
Entered,  4.  5.  99.  Oper.,  6.  5.  99.  Cystectomy.  Still  under 
treatment. 

Amnesis. — Grandmother  died  of  gallstone  disease,  a  cousin 
likewise  suffers  from  cholelithiasis.  For  about  6  years  the  pa- 
tient has  suffered  from  extremely  obstinate  constipation.  Christ- 
mas, 1896,  after  several  days'  discomfort  she  was  attacked  with 
cramp-like  pains  in  the  liver  and  stomach  regions  ;  the  pains 
extended  to  the  back  and  radiated  to  the  breast.  Vomiting  and 
jaundice  did  not  then  occur  ;  the  pains  yielded  to  morphine  and 
purgatives.  The  attending  physician  made  the  probable  diagno- 
sis of  gallstone  disease.  Since  that  time  the  patient  has  never 
felt  right  well  ;  the  attacks,  like  the  one  described  above,  recurred 
almost  at  regular  intervals  of  14  days,  and  were  of  the  most 
varied  intensity.  The  patient  was  very  careful  in  eating,  but 
could  not  determine  a  dependence  of  the  attacks  upon  the  taking 
of  food.  Two  years  ago  the  patient  underwent  an  1 1  weeks 
spring  and  bath  cure  at  Kissingen  ;  there  she  was  thoroughly 
purged,  and  felt  also  the  last  four  weeks  there  quite  well  and 
was  free  from  attacks.  Two  days  after  her  return  again  colic. 
Subsequently  till  now  again  every  2—3  weeks  cohcs  often  with 
violent  vomiting  ;  with  them  never  icterus,  stools  always  consti- 
pated, never  colorless,  never  fever.  The  condition  of  her 
strength  and  nutrition  remained  good  ;  gradually  there  devel- 
oped, however,  in  consequence  of  the  constantly  recurring  at- 
tacks, the  impotence  of  every  treatment  (oil-ether  cures,  packs, 
etc.),  and  the  anxiety  for  the  future  and  the  issue  of  her  disease 
an  excessive  nervousness,  which  the  patient  herself  says  was 
very  burdensome  to  those  about  her.  The  attending  physician 
(Dr.  Kropff  of  Nordhausen),  who  already  had  long  urged  oper- 
ation, now  finally  accomplished  it,  and  referred  her  to  my  clinic. 
The  passage  of  stones  has  never  been  observed  in  spite  of  fre- 
quent search. 

Condition. — Pale  woman,  of  moderate  condition  of  nutrition. 
Gall-bladder  somewhat  sensitive  to   pressure,   no   tumor  to  be 


APPENDIX. 


343 


felt  there.  Liver  somewhat  enlarged  below.  No  icterus,  stools 
brown,  urine  free  from  albumin,  sugar,  bile  pigment.  Everything 
normal  in  the  remaining  abdomen. 

Diagnosis.— Stones  in  the  gall-bladder  (this  slightly  inflamed), 
cysticus  probably  occluded. 

Operation,  6.  5.  99.  Chloroform  anaesthesia.  Longitudinal 
incision  in  the  right  rectus  abdom.  muscle.  Sharp  bleeding 
from  the  abdominal  walls.  Gall-bladder  large,  relaxed,  without 
adhesions.  Liver  extends  to  the  navel  (enteroptosis).  In  the 
cysticus  a  hazelnut-sized  stone.  Excision  of  the  gall-bladder 
without  opening  it.  Sounding  of  the  choledochus  discloses 
normal  conditions.  Suture  of  the  liver  bed  with  thick  catgut. 
Tamponade  with  sterile  gauze.  The  operation  to  the  excision  of 
the  gall-bladder  had  lasted  12  minutes.  Suture  of  the  abdomi- 
nal w^alls  w^ith  through  and  through  interrupted  sutures. 

Remarks. — The  opened  gall-bladder  shows  in  the  cysticus  an 
immovably-wedged  stone,  which  had  caused  a  disappearance  and 
ulceration  of  the  mucous  membrane.  Had  one  done  in  this  case 
a  cystostomy,  then  surely  a  stricture  and  obliteration  of  the 
cysticus  would  have  occurred.  The  content  of  the  gall-bladder 
was  thickened  pus  of  the  consistence  of  mortar.  It  was  so 
viscid  it  could  not  have  been  at  all  removed  by  cystostomy.  The 
only  intelligent  procedure  was  the  excision  of  the  gall-bladder, 
all  others  absolutely  wrong.  The  wedging  of  the  stone  in  the 
cysticus  was  of  long  duration,  already  existing  for  months  ;  the 
stone — a  beautiful,  warty,  crystal-clear  cholestearin  stone — had 
regularly  eaten  into  the  mucous  membrane.  The  course  was 
without  any  reaction.  Removal  of  the  tampon  on  the  14th 
day. 

We  met  ivitJi  a  cJiroiiic  dropsy  in  an  already  contracted  gall- 
bladder in  the  following  case  : 

Mrs.  W.,  44  years,  wife  of  a  commercial  councillor,  from 
Danzig.  Entered,  20.  4.  99.  Oper.,  21,  4.  99.  Cystectomy. 
Cysticotomy.      Discharged  cured,  25.  5.  99 

Amnesis. — Mother    of  the    patient    is    living    and    in    good 


344  GALLSTONE  DISEASE. 

health  save  for  gout ;  father  is  dead  (diabetes).  Mrs.  W.  was 
entirely  well  until  4  years  ago ;  then  she  was  taken  with  a 
cramp-like  pain,  which  had  its  seat  in  the  back  and  breast  and 
was  extremely  violent.  Morphine  injection  with  good  result. 
Then  two  years  pause  ;  stomach  very  good,  no  pains.  Now 
new,  seldom  occurring  attacks,  less  violent  than  the  first ;  the 
pain  was  not  in  the  right  upper  part  of  the  abdomen,  and  is  not 
felt  as  a  cramp  of  the  stomach  ;  it  is  localized  rather  in  the  oesoph- 
agus for  the  most  part.  The  attacks  were  attended  by  vom- 
iting, but  not  by  jaundice  ;  the  vomiting  has  occurred  toward 
the  end  of  the  attack.  1898,  cure  in  Carlsbad  ;  there  no  attack. 
Then,  as  she  declares  since,  the  strict  diet  ordered  was  not  ad- 
hered to,  attacks  at  y^  year  intervals.  Pain  not  very  severe. 
Finally  homoeopathic  treatment  with  strict  diet ;  in  consequence 
loss  of  flesh  of  about  20  pounds.  At  present  constant  sensation 
of  pressure  in  the  oesophagus  and  burning  in  stomach.  Appetite 
good.      No  pain  in  the  region  of  the  liver. 

Status  Prsesens. — Slight  sensitiveness  to  pressure  in  the  re- 
gion of  the  gall-bladder.  Liver  not  enlarged.  No  icterus. 
Heart  and  lungs  normal.      Urine  normal. 

Diagnosis. — Stones  in  the  gall-bladder  and  cystic  duct. 
Chronic  cholecystitis.  Gall-bladder  probably  already  con- 
tracted. 

Operation. — Longitudinal  incision  in  right  rectus  muscle  of 
12  cm.  in  length.  The  gall-bladder  lies  high  up  under  the 
liver  and  is  with  difficulty  accessible.  With  difficulty  one  suc- 
ceeds in  drawing  this  up,  and  by  aspiration  in  removing  from  it 
30  ccm.  of  muddy  serous  fluid.  Two  concretions  were  felt  loca- 
ted high  up  ;  one  was  pushed  into  the  fundus,  and  was  squeezed 
out  of  the  transverse  incision  made  in  the  fundus,  the  other 
could  not  be  moved.  The  gall-bladder  was  clamped  provision- 
ally and  an  incision  made  upon  the  concretion  in  the  neck.  After 
this  was  extracted  removal  of  the  bladder  above  the  neck. 
Separate  ligature  of  the  cysticus  and  cystic  artery  with  catgut. 
Sterile  gauze  strips  in  the  foramen  of  Winslow,  into  a  moderately 


APPENDIX. 


345 


bleeding  tear  in  the  liver  above  this,  occasioned  by  the  strong 
pulling  upon  the  gall-bladder  and  upon  the  liver  bed.  Closure 
of  the  abdominal  wound  by  interrupted  through  and  through 
sutures  and  a  few  skin  sutures.  Tampon  brought  out  of  the 
upper  angle  of  the  wound. 

Course.— Afebrile,  not  over  37.6°  C.  Pulse  accelerated  to 
100,  to  reach  130  on  the  3d  day.  Belly  distended,  but  not 
painful.  In  the  belly  there  were  borborygmi  24  hours  after 
operation  ;  despite  glycerine  enemata  and  rectal  tube  no  flatus 
passed.  With  this  a  great  deal  of  eructation.  During  the  night 
of  the  22.  23.  4.  twice  vomiting  of  green  masses.  One  supposes 
acute  dilatation  of  the  stomach.  Outwashing  of  the  stomach. 
Contents  small.  For  60  hours  after  the  operation  still  no  flatus 
has  passed  ;  the  pulse  beats  140;  irrigations  and  glycerine  ene- 
mata are  without  result ;  the  patient  is  given  2  teaspoonfuls  of 
cascara  sagrada.  Upon  this,  rumbling  in  the  abdomen  and  pas- 
sage of  flatus.  Pulse  becomes  stronger,  and  is  during  the  night 
of  23.  24.,  112.  No  fever.  The  next  morning  the  patient 
looks  better.  Pulse,  92.  Temp.,  37.3°  C.  No  vomiting. 
Great  weakness.  The  absence  of  flatus,  the  cessation  of  peri- 
stalsis after  laparotomies  is  always  a  great  anxiety  for  the  sur- 
geon. Without  that  there  is  the  slightest  inflammation,  the 
belly  can  become  distended,  the  pulse  accelerated  and  small  ;  if 
the  peristalsis  comes  into  action,  then  in  an  instant  the  condition 
is  changed.  The  pulse  becomes  slow  and  strong,  the  eructa- 
tions cease,  the  restlessness  disappears.  From  the  5th  day  on 
very  good  course,  patient  gains  daily,  and  feels  so  well  already 
on  the  8th  day  that  she  wishes  to  get  up.  On  the  1 2th  day 
change  of  dressings.  Wound  healed  by  first  intention.  Remo- 
val of  tampon.      Very  good  condition. 

Remarks. — The  patient  had  a  chronic  dropsy  in  a  markedly 
contracted  gall-bladder.  The  liver  was  completely  normal.  The 
pain  which  the  cysticus  stone  or  the  obstructed  secretion  caused 
in  the  gall-bladder  was  felt  more  in  the  breast,  in  the  oesopha- 
gus. The  results  of  palpation  normal  save  for  the  slightest  sen- 
29 


346 


GALLSTONE  DISEASE. 


sitiveness  to  pressure  on  deep  expiration.  No  icterus.  No 
tumor.  The  indication  was  given  by  the  inability  to  bear  the 
Carlsbad  cure  and  by  the  loss  in  a  brief  time  of  about  30 
pounds.  The  stone  in  the  cysticus  was  so  immovably  seated 
that  any  sort  of  a  dislodgment  was  impossible.  Adhesions 
were  present  on  the  cysticus  stretching  to  the  choledochus. 

In  the  folloiuing  case  the  pericholecystitis  attacked  the  pylorus  so 
that  the  symptoms  of  a  stomach  disease  were  more  prominent : 

Mrs.  H.,  from  Hotensleben,  wife  of  an  official.  Entered,  19. 
4.  99.  Oper.,  20.  4.  99.  Cystectomy.  Pyloroplasty.  Dis- 
charged, 29.  5.  99.      Cured. 

Amnesis. — Father  died  ten  years  ago,  at  the  age  of  60,  of 
stomach  trouble.  Mother  is  living  and  healthy.  Mrs.  H.  was 
as  a  child  healthy  ;  married  at  22  years.  Mother  of  two  children, 
of  which  one  is  living  and  healthy  ;  4  abortions.  For  four  years 
Mrs.  H.  has  had  colic  attacks  in  the  right  side  and  back  ;  never 
jaundiced  ;  sometimes  vomiting  with  the  attacks  and  fever ;  by 
the  physician  liver  enlargement  was  made  out.  In  the  previous 
year  Dr.  Boas  of  Berlin  diagnosticated  gallstones.  Patient  has 
lost  in  all  some  ten  pounds,  the  appetite  is  poor,  there  are  eruc- 
tations, stools  are  constipated. 

Status   Praesens Small,    delicate,    thin    woman.       Organs 

normal,  liver  not  enlarged,  apparent  (slight)  resistance  under  the 
right  rectus  abdominal  muscle  extending  to  the  navel.  In  the 
stomach  in  early  morning  one  may  occasion  succussion  sounds, 
the  upper  limits  of  the  stomach  at  the  7th  rib,  the  lower  2 
finger-breadths  below  the  navel.  Pulse  regular,  somewhat 
small,  84  ;  temp,  normal. 

Diagnosis. — Dropsy  of  the  gall-bladder.  Obstruction  of  the 
cysticus.  Atony  of  the  stomach  (peripyloritis).  Small  incision 
in  the  right  rectus  abdominal  muscle,  thin  abdominal  walls. 
Gall-bladder  adherent  to  the  large  omentum  below  the  pylorus. 
Kinking  of  the  pylorus.  On  attempting  to  separate  the  ad- 
hesions between  the  fundus  of  the  gall-bladder  and  the  omentum 
pus  appears.      Opening  of  a  pericholecystitic  pus   collection   of 


APPENDIX. 


347 


walnut  size.  Curettage  of  the  abscess  in  omentum.  The  sero- 
purulent  fluid  pressing  out  of  the  opened  gall-bladder  is  sponged 
up  and  a  great  quantity  of  small  stones  extracted.  Temporary 
tampon  of  the  gall-bladder.  Pyloroplasty  in  typical  manner  on 
account  of  cicatricial  contraction  of  the  pylorus  (peripyloritis). 
Exposure  of  the  choledochus  after  division  of  both  folds  of  the 
ligamentum  hepatoduodenale.  Choledochus  free.  Division  of 
the  cysticus  near  the  choledochus.  Separate  ligature  of  the 
cysticus  with  catgut.  Tampon  of  the  cysticus  and  the  liver 
wound  which  was  stitched  with  catgut.  Tampon  in  the  curetted 
omental  abscess.  Closure  of  the  abdominal  wound  with  through 
and  through  interrupted  silk  suture,  and  a  few  skin  sutures. 
Tampon  brought  out  the  upper  angle  of  wound.  Duration,  70 
minutes. 

Course. — No  fever  and  no  vomiting.  Tampon  removed  in 
14  days.  Patient  gets  up  the  16.  5.  Good  appetite.  Dilata- 
tion of  the  stomach  gone.  Wound  almost  healed.  Marked  in- 
crease in  weight. 

Remarks. — The  gall-bladder  contained  many  stones,  the  cys- 
ticus was  dilated  in  a  diverticular  manner,  the  transition  to  the 
choledochus  on  the  one  side  and  the  gall-bladder  on  the  other 
very  small,  so  that  only  a  small  probe  could  be  passed.  Be- 
tween these  narrow  ducts  lay  a  cherrystone-sized  stone.  The 
stone  was  lodged  completely  enveloped  by  mucous  membrane. 
The  pathological  condition  with  Mrs.  H.  is  very  instructive.  In 
the  gall-bladder  many  stones,  cysticus  likewise  occluded.  Its 
content  was  muddy  fluid  with  bacterium  coli.  An  abscess  lay 
between  the  fundus  of  the  gall-bladder  and  the  omentum.  A 
perforation  of  the  gall-bladder  was  not  to  be  detected.  The 
pericholecystitis  had  attacked  the  pylorus  and  strictured  it,  so 
that  a  pyloroplasty  was  necessary.  The  patient  had  already 
had  the  abscess  a  long  time.  The  patient  came  solely  to  be  ex- 
amined and  her  determination  to  have  an  immediate  operation 
was  very  correct,  for  one  could  not  foresee  whither  the  abscess 
would  break  through.    That  the  pus  could  have  been  inspissated 


348  GALLSTONE  DISEASE. 

was  possible,  but  improbable.  The  case  shows  how  difficult  it 
is  many  times  on  the  strength  of  palpation  to  find  an  indication 
for  operation. 

/;/  the  following  case  there  were  marked  pains  present  in  the  pit 
of  the  stomach.  One  pliysician  had  diagnosticated  gallstones,  the 
second  idcer  of  the  stoifiach,  the  third  ?iervous  dyspepsia.  I  found 
a  hernia  of  the  linea  alba,  and  besides  also  an  idcns  duodeni 
sanatum  : 

Mr.  E.  KL,  29  years,  factory  owner,  from  Freyburg,  a.  d.  Un- 
strut.  Entered,  8.  5.  99.  Oper.,  10.  5.  99.  Discharged,  31.  5. 
99.  Cured.  Gastroenterostomy.  Operation  for  a  hernia  \\\  the 
linea  alba. 

Amnesis. — Family  history  without  importance,  except  that 
the  grandmother,  on  his  mother's  side,  who  died  of  senility,  as 
the  autopsy  showed,  suffered  from  gallstones.  The  father  of 
Mr.  Kl.  died  of  softening  of  the  brain,  the  mother  is  living  and 
healthy.  The  patient  was  perfectly  healthy,  but  already  with 
his  9th  year  occurred  cramp-like  pains  in  the  pit  of  the  stomach, 
which  radiated  toward  the  stomach  and  liver,  and  further  to  both 
sides  towards  the  back.  Their  duration  in  single  attacks  was 
not  less  than  a  day,  yet  there  were  attacks  of  much  longer  dura- 
tion. The  attacks  which  in  the  first  years  occurred  rarely,  about 
twice  a  year,  later  at  times  daily  of  recent  years,  reach  an  almost 
unendurable  height.  By  pressure  upon  the  pit  of  the  stomach 
the  pain  was  usually  diminished.  Three  times  the  attacks  were 
attended  by  vomiting.  In  1889  a  physician  in  Halle  a.  S.  diag- 
nosticated gallstones,  with  attention  to  the  then  existing  jaun- 
dice, which  lasted  approximately  4  weeks.  Passage  of  stones  ^ 
was  never  observed.  An  internal  treatment,  which  was  at  thattj 
time  followed,  had  apparently  a  good  effect  in  so  far  as  the  at- 
tacks of  pain  did  not  recur  until  1892.  1893,  consultation  of 
Professor  Stintzing  of  Jena,  who  after  a  week's  observation  sent 
the  patient  to  Carlsbad.  There  excellent  success,  no  pains  ;  the 
next  year  again  cure  at  Carlsbad  with  the  same  success,  which 
lasted  about  2  years.      1897,  on  account  of  renewed  attacks   of 


APPENDIX.  349 

pain,  examination  by  Prof.  v.  Mehring  of  Halle  a.  S.,  who  es- 
tablished an  excess  of  stomach  acids.  Upon  his  advice  the  pa- 
tient drank  at  home  Bilin  water,  which  subjectively  acted  well  ; 
without  that,  however,  a  definite  cure  was  attained.  It  is  note- 
worthy still  that  pains,  which  did  not  show  any  dependence  upon 
meals  or  errors  of  diet,  were  favorably  influenced  by  changes  of 
air.  The  appetite  was  excellent,  pains  in  the  stomach  never 
existed.  Mr.  Kl.  is  of  the  opinion  that  he  suffers  from  gall- 
stones. 

Status  Prsesens. — Medium-sized,  powerful,  well-nourished 
man.  Organs  normal.  Urine  normal.  No  enlargement  of  the 
liver.  No  pain  on  pressure  in  the  region  of  the  gall-bladder.  In 
the  linea  alba,  between  the  navel  and  the  xiphoid  process,  an  ex- 
tremely circumscribed  and  very  painful  place,  under  it  a  clear 
hazelnut-sized  resistance.  The  patient  asserts  with  positiveness 
that  the  pains  originate  in  this  place.  Nothing  especial  in  the 
contents  of  the  stomach. 

Diagnosis. — Hernia  of  the  linea  alba.  Perhaps  behind  it  ad- 
hesions (gall-bladder,  ulcus  ventriculi).  Patient  urgently  wishes 
an  operation,  since  he  is  tired  of  life. 

Operation,  lO.  5.  99.  Longitudinal  incision  in  the  median 
line  from  xiphoid  process  downwards  to  the  navel.  The  hernia 
of  the  linea  alba  is  scarcely  cherry  size,  the  hole  in  the  fascia  is 
laid  open,  the  bands  of  omentum  here  adherent  separated  and 
dropped.  Resection  of  the  prse  and  subperitoneal  fat.  Gall- 
bladder free  from  stones  and  adhesions.  Pylorus  hypertrophied, 
in  the  duodenum  on  the  part  turned  to  the  pancreas  an  about 
walnut-size  very  hard  resistance  (completely  healed  ulcus  du- 
odeni).  The  duodenum  is  firmly  fixed,  the  spot  over  the  ulcer 
shows  radiating  scars.  To  avoid  all  later  consequences  gastro- 
enterostomy after  Wolfler.  One-hour  operation.  Good  chloro- 
form anaesthesia.  Suture  of  the  abdominal  walls  after  Spencer 
Wells. 

Course. — Admirable.  Pain  no  longer  present.  No  vomiting 
of  bile.      Patient  is  up  the  14th  day  and  feels  very  well. 


350  GALLSTONE  DISEASE. 

Remarks. — There  was  nothing  pathological  to  be  discovered 
in  the  gall-bladder,  gallstones  were  not  present.  The  circum- 
scribed sensitiveness  to  pressure  in  the  median  line  spoke  for 
hernia  of  the  linea  alba,  which  was  also  found.  Since  I  operate 
upon  herniae  of  that  sort  by  widely  opening  the  abdomen,  I  have 
enlightened  myself  concerning  the  pylorus,  duodenum  and  gall- 
bladder, and  since  I  found  the  firm  spot  in  the  duodenum,  I  im-' 
mediately  decided  upon  gastroenterostomy.  Who  will  say  with 
positiveness  that  pains  proceeded  only  from  the  hernia  ?  If  one 
operates  upon  this  alone  and  the  pains  remain,  then  one  would 
have  regretted  not  having  done  the  gastroenterostomy,  which, 
when  the  abdomen  was  once  opened  in  a  healthy  man,  does  not 
actually  complicate  the  procedure.  Although  from  the  first  it 
was  clear  to  me  that  no  cholelithiasis  was  present — for  the  dis- 
tress did  not  indicate  it — I  report  the  case  since  it  is  of  interest 
for  the  differential  diagnosis. 

Although  in  the  next  case  jaundice  zuas  absolutely  wantino-^  the 
hepaticus  and  choledochus  zuere  jammed  full  of  stones. 

Mrs.  E.  W.,  55  years,  wife  of  a  merchant,  of  Berlin.  Entered, 
7.  5.  99.  Open,  9.  5.  99.  Ectomy,  choledochotomy  and  drain- 
age of  the  hepaticus.      Still  under  treatment. 

Amnesis — Family  history  and  previous  life  give  no  import- 
ant data  for  the  diagnosis  of  the  disease.  Twenty-seven  years 
ago  the  patient,  who  up  till  then  had  always  enjoyed  good 
health,  fell  ill  about  14  days  after  a  confinement  with  a  cramp  in 
the  stomach  (the  pains  occurring  in  paroxysms  in  the  stomach 
and  liver  region,  and  radiating  to  the  back  and  the  right 
shoulder).  Morphine  in  powder  gradually  brought  improve- 
ment. In  the  succeeding  months  and  years  attacks  of  this  kind 
occurred  at  greater  or  less  intervals  without  jaundice  ever  ap- 
pearing. In  the  period  of  freedom  from  attacks  the  patient  com- 
plained constantly  of  distress  and  a  pressing  mysterious  pain  in 
the  region  of  the  liver.  She  was  regarded  as  having  stomach 
trouble  and  treated  for  this.  Cures  in  Kissingen  and  Franzens- 
bad  were  without  any  effect.      Twenty-three  years   ago  violent 


APPENDIX. 


35 


typical  attack  at  the  Baltic  sea  resort  Cranz,  soon  after  a  cold  bath  ; 
with  it  marked  icterus,  colorless  stools,  no  fever,  no  vomiting. 
Gradually  almost  the  entire  trouble  disappeared  ;  feeling  of 
pressure  and  distress,  however,  remained  permanently,  so  that 
the  patient  was  always  regarded  as  having  stomach  trouble.  In 
the  following  years  colics  at  long  intervals. 
'  Eighteen  years  ago,  again  in  Cranz,  a  severe  painful  attack 
with  icterus — now  for  the  first  time  the  diagnosis  of  gall-stones 
was  made.  Patient  went  home  ;  after  a  short  interval  of  rest 
again  a  severe  attack  with  jaundice.  Afterwards  a  Carlsbad 
cure  in  Carlsbad;  during  the  time  of  the  **  cure "  persistent 
slight  jaundice,  stomach  and  digestive  troubles.  (In  Carlsbad 
development  of  a  periproctitic  abscess,  which  healed,  leaving  be- 
hind a  fissure  of  the  anus,  which  was  later  operated  upon  by 
Prof  J.)  Fourteen  days  after  the  return  from  Carlsbad  severe 
attack  with  jaundice  and  enlargement  of  the  liver.  Seven 
months  later  patient  again  visited  Carlsbad  ;  there  she  was  this 
time  also  never  entirely  free  from  light  attacks  and  from  pressing 
pains  in  the  region  of  the  gall-bladder,  varying  in  severity. 
Then  suddenly  again,  without  apparent  occasion,  a  violent  at- 
tack with  icterus  ;  after  several  days  they  found  a  pea-sized 
stone  in  the  stools.  Patient  now  yearly  (about  14  times)  visited 
Carlsbad,  but  nevertheless  is  not  relieved  of  her  attacks  and 
other  distress.  The  attacks  occurred  irregularly,  despite  the  most 
careful  diet,  very  frequently  (more  exact  information  regarding 
the  number  of  attacks  which  she  has  suffered  in  this  long  period 
the  patient  cannot  give)  they  were  often  associated  with  icterus 
and  colorless  stools,  and  were  not  influenced  by  the  Carlsbad 
cures.  Eight  years  ago,  after  a  severe  colic  in  Norderney,  oil 
treatment ;  afterwards  for  almost  two  years  extremely  severe  di- 
gestive trouble  (loss  of  appetite,  flatulence).  After  the  oil  treat- 
ment, massage  treatment  (abdominal  massage),  in  the  course  of 
which  a  stone  passed.  Since  four  months  homoeopathic  treat- 
ment, after  which  obstinate  constipation  developed. 

Stated  briefly,  the  patient  has  suffered  for  27  years  from  ex- 


352 


GALLSTONE  DISEASE. 


tremely  frequently  occurring  gallstone  colics,  which,  from  time 
to  time,  were  associated  with  icterus  ;  3  times  stones  have  been 
passed.  In  the  intervals  almost  constant  pressure  in  the  region 
of  the  gall-bladder.  Never  fever,  very  rarely  vomiting.  In  re- 
cent years  very  annoying  flatulence  and  constipation.  Medicinal, 
bath  and  mechanical  treatment  up  till  the  present  absolutely 
without  success.  Patient  comes  hither  upon  the  advice  of  Prof 
Dr.  Landau  of  Berlin. 

Status  Prsesens. — Small,  very  corpulent  woman,  heart  and 
lungs  normal,  in  urine  nothing  abnormal.  Right  lobe  of  the 
liver  large,  hangs  deeply  in  the  abdomen,  liver  not  enlarged. 
Gall-bladder  region  somewhat  sensitive  to  pressure,  no  tumor  of 
the  gall-bladder,  no  icterus. 

Diagnosis. — Stones  in  the  gall-bladder  ;  chronic  cholecystitis 
in  an  already  markedly  altered,  dropsical,  contracted  and  ad- 
herent gall-bladder. 

Operation,  9.  5.  99.  (In  the  presence  of  Dr.  Th.  Landau.) 
Incision  in  the  right  rectus  abdominal  muscle  from  curvature  ot 
ribs  downwards.  Opening  of  the  abdomen,  liver  border  ad- 
herent with  the  omentum  and  intestines.  Separation  with 
Cooper's  scissors  ;  the  gall-bladder  lies  far  to  the  left,  and  is  ad- 
herent to  the  duodenum  and  omentum.  Very  difficult  separa- 
tion. In  the  fundus  of  the  gall-bladder  a  perforation,  from 
which  a  stone  escapes.  Opening  of  the  gall-bladder  in  the 
fundus  ;  removal  of  many  small  pea-sized  stones.  In  cysticus,  a 
stone  the  size  of  a  hazelnut.  Cysticotomy.  On  palpation  of 
the  hepaticus  and  choledochus  different  stones  were  detected. 
Division  of  the  cysticus  even  into  the  choledochus.  Removal 
of  several  bile-obstructing  stones  from  the  hepaticus  and  chole- 
dochus. Since  the  entire  hepaticus  was  covered  with  blackish 
stone  fragments,  the  drainage  of  the  hepaticus  was  carried  out 
through  a  thin-walled  tube.  The  gall-bladder  was  extirpated. 
From  the  duodenal  part  of  the  choledochus  a  hazelnut-sized 
concretion  was  removed.  Ligature  of  the  cystic  artery.  Closure 
of  the  incision  in  the  choledochus.     Tube  in  the  hepaticus,  tam- 


APPENDIX.  353 

ponade  with  sterile  gauze.  Suture  of  the  abdominal  wall  with 
interrupted  through  and  through  sutures.  Dressing.  Duration 
of  operation,  one  hour  ;   chloroform  anaesthesia. 

Remarks. — The  diagnosis  was  only  made  of  old  gallstone 
trouble  in  the  gall-bladder.  No  one  could  imagine  that  there 
were  stones  in  the  hepaticus  and  choledochus.  At  the  time  there 
existed  neither  icterus,  liver  enlargement  nor  colics.  The  case 
teaches  that  stones  may  occur  in  the  choledochus  and  remain 
there  for  years,  without  that  the  patient  has  the  slightest  dis- 
comfort. After  the  removal  of  the  gall-bladder  and  the  suture 
of  the  opening  in  the  cysticus,  I  pushed  a  rubber  tube  6  cm.  into 
the  hepaticus,  since  muddy  bile  escaped  and  a  quantity  of  stone 
fragments  had  remained  behind  in  the  hepaticus.  Whoever  in 
such  a  case  does  an  ideal  choledochotomy  cannot  wonder  if  he 
experiences  recurrences.  In  such  cases  the  exposure  of  the  bile- 
duct  system  is,  under  all  circumstances,  necessary,  and  I  have 
already  for  a  long  time  expressed  the  principle  that  with  every 
gallstone  operation  the  exposure  of  the  cysticus  and  choledochus 
is  indicated,  and  that  one  ought  not  to  fear  to  open  up  these 
ducts  when  one  has  the  suspicion  of  the  presence  of  stones.  If 
one  finds  none,  then  this  kind  of  incision  does  no  harm,  for  the 
bile  in  so  doing  is  sterile,  but  if  one  finds  stones  the  incision  was 
necessary.  At  all  events,  I,  by  reason  of  recent  experience,  take 
the  standpoint  that  one  cannot  be  active  enough  in  the  palpation 
and  incision  of  the  bile  ducts,  and  that  conservatism  has  abso- 
lutely no  place  in  gallstone  surgery.  An  advance  in  the  opera- 
tive treatment  of  gallstone  disease  will  only  then  take  place  when 
we  treat  the  cysticus,  hepaticus  and  choledochus  just  as  the  gall- 
bladder ;  that  is,  when  we  open  and  drain  them.  Only  in  this 
way  will  we  attain  good  results,  and  be  able  to  protect  ourselves 
from  the  reproach  that  we  overlook  stones.  I  must  openly  admit 
that  in  this  case  I  have  never  thought  of  stones  in  the  choledo- 
chus, since  not  a  trace  of  icterus  or  liver  enlargement  pointed 
in  that  direction.  I  have  no  doubt  that  the  stones  had  already 
tarried  years  in  the   choledochus  of  the  patient ;  and  I   can  only 


354  GALLSTONE  DISEASE. 

repeat  what  I  have  emphasized  in  the  first  part  of  my  book,  that 
even  large  stones  may  tarry  months  or  years  in  the  choledochus 
without  causing  the  shghtest  symptoms.  This  case  proves  that 
a  special  diagnosis  is  not  always  to  be  made  ;  latent  stones  in  the 
gall-bladder  and  in  the  choledochus  withdraw  themselves  from 
our  demonstration,  and  at  most  we  are  from  the  history  in  po- 
sition to  form  an  approximate  picture  of  the  site  of  the  stone. 
The  course  is  admirable  and  completely  reactionless.  On  the 
5th  day  stool,  condition  good.  Profuse  escape  of  bile  from  the 
tube  (up  to  600  gr.). 

1)1  the  folloiving  case  jaundice  existed  four  years  zuithoiit  pain. 
Whether  a  disease  of  the  liver  existed  or  whether  the  chole- 
dochus was  occluded  (stones  and  adhesions)  was  difficult  to  de- 
termine. On  account  of  unbearable  itching,  unrelieved  by  any 
means,  the  patient  decided  for  an  exploratory  incision. 

Mr.  X.,  from  X.  Entered,  12.  5.  99.  Open,  16.  5.  99.  Cys- 
togastrostomy.     Still  under  treatment. 

Amnesis. — Cause  of  father's  death  unknown,  mother  died  of 
dropsy,  brother  of  pleurisy.  Family  history  of  no  importance  ; 
likewise  the  previous  life.  About  18-20  years  ago  the  patient 
suffered  at  night,  almost  without  exception,  from  cramps  in  the 
stomach,  which  occurred  4-5  times  ;  yielded  to  morphine,  and 
without  any  reminder  left  after  several  hours.  About  this  time, 
rather  somewhat  earlier,  the  patient  acquired  lues,  which  was  sys- 
tematically treated,  and  in  consequence  gave  rise  to  no  further 
symptoms.  Four  years  ago,  w^ithout  pains  or  colic,  jaundice  ap- 
peared ;  from  time  to  time  there  was  fever  ;  with  it  marked  ema- 
ciation and  loss  of  appetite.  Cure  in  Kissingen,  then  in  Carls- 
bad. In  August,  1895,  Prof.  F.  made  the  diagnosis  of  cancer 
of  the  liver.  September,  1895,  with  Prof.  M.,  no  operation,  di- 
agnosis syphilitic  liv^er.  March,  1896,  on  this  account,  Wies- 
baden, there  inunction  cure  ;  at  that  time  the  liver  is  said  to  have 
been  hard  and  enlarged.  In  addition  to  the  inunction  treatment, 
oil  treatment ;  after  this  the  liver  is  said  to  have  become  softer. 
Nev^er  pains.      For  two  years   persistent  jaundice  ;  tuiendurable 


APPENDIX.  355 

coiitimions  itcJiing  of  the  skill ;  countless  remedies  employed 
against  it.  Urine  is  said  since  that  time  to  occasionally  contain 
bile  pigment,  sometimes  completely  free  ;  likewise  the  stools  are 
said  to  change  color  (patient  drinks  freely  of  milk),  sometimes 
clay-colored,  sometimes  normal  brown.  No  diarrhoea,  no  con- 
stipation. No  pains,  no  feeling  of  pressure,  no  distress  in 
stomach  or  gall-bladder  regions,  no  backaches. 

Status  Prsesens.— Powerful,  fairly-well  nourished  man,  with 
moderate,  but  quite  evident  jaundice.  Liver  markedly  enlarged 
below,  right  lobe  extends  below  the  navel.  Upper  surface  of 
liver  smooth,  not  irregular,  only  very  slightly  sensitive  to  pres- 
sure.     In  the  urine  bile  pigment,  neither  albumin  nor  sugar. 

Diagnosis  impossible.  Against  stones  is  the  absence  of 
pains,  and  the  continuous  never  changing  jaundice  ;  for  stones 
is  the  fever.  The  liver  surface  is  smooth,  not  knobby.  Perhaps 
there  are  only  adhesions  to  the  choledochus.  (Syphilitic  liver 
disease  ?)  Patient  desires  relief  from  his  fearful  itching  so  that 
the  proposal  of  an  exploration  seems  to  be  justifiable. 

Operation,  i6.  5.  99.  Typical  longitudinal  incision.  Liver 
large.  Upper  surface  smooth.  Gall-bladder  completely  invested 
in  adhesions.  Especially  deep  down  one  feels  after  separation 
of  adhesions  between  omentum  and  gall-bladder  several  tense 
adhesions  which  spread  out  between  the  gall-bladder  and  hga- 
mentum  hepato-duodenale.  The  choledochus  tensely  distended, 
so  soon  as  the  bands  of  adhesions  were  severed  the  gall-bladder 
collapses-.  For  safety,  after  that  the  choledochus  is  shown  free 
from  stones,  an  anastomosis  was  made  between  the  stomach  and 
gall-bladder.  Duration  of  the  operation  about  i  1/  hours.  Good 
chloroform  anaesthesia.     Complete  closure  of  the  abdomen. 

Remarks. — The  cramps  of  the  stomach  occurring  20  years 
ago  were  surely  gallstone  colics.  The  adhesions  were  cord- 
like and  so  hindered  the  escape  of  bile  into  the  intestine.  A 
positive  diagnosis  in  such  cases  will  never  be  possible.  The 
anastomosis  between  gall-bladder  and  stomach  upon  which  I 
reluctantly  determined  was  necessary  in  order  to  meet  new  dis- 
turbances. 


356  GALLSTONE  DISEASE. 

Ill  tlie  follozving  case  there  zvas  a  cholecystitis  zvith  simultaneous 
occlusion  of  the  choledochus. 

L.  G.,  36  years,  wife  of  a  laborer,  from  Minsleben.  Entered 
17.  4.  99.  Operation,  22.  4.  99.  Choledochotomy.  Cystec- 
tomy.     Still  under  treatment. 

Amnesis. — The  mother  of  the  patient  is  said  to  have  suffered 
from  the  same  colics  as  those  from  which  the  patient  now  suf- 
fers. Family  history  and  previous  life  otherwise  of  no  import- 
ance. Five  years  ago  the  patient  was  taken  for  the  first  time 
with  violent  cramp-like  pains  in  the  region  of  the  stomach,  which 
radiated  toward  the  back  and  shoulders,  lasted  several  hours, 
and  were  attended  and  followed  by  vomiting,  weakness,  and  pros- 
tration. Whether  icterus  has  occurred  during  the  attacks  the 
patient  cannot  say  positively.  The  attacks  recurred  at  intervals 
of  weeks  or  months,  strikingly  often  they  occurred  either  just 
before  or  just  after  the  menstruation.  About  three  weeks  ago 
the  patient  after  a  very  painful  attack  was  yellow  for  several  days  ; 
at  this  time  the  stools  were  colorless  ;  the  urine  is  said  to  have 
been  reddish-brown.  The  jaundice  did  not  attain  an  especially 
high  degree  ;  the  patient  had,  however,  persistent  pressing  pains 
in  the  liver  and  stomach  regions  which  radiated  to  the  back. 
For  some  days  the  patient  has  noticed  a  striking  almost  sudden 
occuring  improvement  of  her  distress  for  which  she  knows  no 
reason.  At  the  present  she  complains  still  of  pressure,  weak- 
ness, poor  appetite. 

Result  of  Examination. — Liver  not  enlarged,  sHght  sensitive- 
ness to  pressure  in  the  region  of  the  gall-bladder.  Moderate 
icterus.      In  the  urine  bile  pigment,  no  albumin. 

Diagnosis. — Choledochus  obstruction  with  stones.  Stones 
will  also  be  found  in  the  gall-bladder. 

Operation,  22.  4.  99.  Good  chloroform  anaesthesia.  Dura- 
tion, I  yl  hours.  Longitudinal  incision  in  the  right  rectus  ab- 
dominal muscle.  Liver  not  enlarged.  Gall-bladder,  filled  with 
stones,  is  of  the  size  of  a  pear.  Adhesions  to  the  stomach. 
Separation.      Exposure  of  the  choledochus.     In  it  a  stone.     The 


APPENDIX.  357 

gall-bladder  is  first  opened.  Little  muddy  fluid.  Many  stones. 
Walls  much  thickened.  In  cysticus  a  cherrystone-sized  stone. 
It  was  sought  after  clearing  out  the  gall-bladder  to  press  this 
from  the  gall-bladder  into  the  choledochus,  whilst  one  elevated 
the  liver  after  the  manner  of  Rose,  which  stretches  the  gall- 
bladder as  much  as  possible.  The  probe  is  constantly  caught  in 
the  neck  of  the  gall-bladder.  The  cysticus  passes  almost  at  a 
right  angle  from  this  into  the  choledochus.  Choledochotomy. 
Removal  of  the  stone.  Sounding  of  the  choledochus  and  he- 
paticus.  The  gall-bladder  is  extirpated,  in  doing  which  the  rela- 
tions of  the  cysticus  to  the  gall-bladder  and  choledochus  are 
especially  observed.  Each  convinced  himself  that  it  also  in  this 
case  was  impossible  from  the  gall-bladder  to  clear  out  the  chole- 
dochus. The  hand  introduced  into  Winslow's  foramen  detected 
2  stones,  of  which  one  lay  in  the  choledochus  easy  to  reach  ;  the 
other,  lying  higher  up,  belonged  to  the  cysticus.  The  cysticus 
was  displaced  far  upwards,  so  that  the  choledochus  in  fact  lay 
deeper,  that  is,  for  the  finger  more  accessible  than  the  cysticus. 
Closure  of  the  cystic  artery,  the  incision  in  the  cysticus  and  the 
incision  in  the  choledochus  by  sutures  of  catgut.  Tamponade. 
Suture  of  abdominal  walls.  Small  pulse.  Camphor-ether  injec- 
tions. Salt  solution  subcutaneously.  Pulse  improved.  The 
course  was  afebrile.  On  the  8.  5.  99  change  of  dressings.  The 
tamponing  gauze  is  removed  with  salt  solution  irrigation. 
Smooth  healing  of  the  wound.  Removal  of  sutures.  New 
tamponade.  The  sutures  of  the  cysticus  and  choledochus  have 
held.      Good  general  condition,  admirable  appetite. 

Remarks. — The  inflammatory  process,  by  reason  of  which 
the  colics  have  occurred,  was  clearly  to  be  seen.  The  gall- 
bladder was  markedly  thickened,  the  cysticus  occluded,  adhe- 
sions present.  Despite  the  lodgment  of  a  stone  in  the  choledo- 
chus, there  was  no  enlargement  of  the  liver  present.  The 
infection  was  at  the  time  extinguished,  there  were  neither  pains 
nor  fever.  Rose's  endeavors  to  supplant  choledochotomy  and 
extirpation  of  the  gall-bladder  by  clearing  out  of  the  ducts  from 


358  GALLSTONE  DISEASE. 

the  incision  of  the  gall-bladder  showed  itself  in  this  case,  as 
almost  always,  impossible  of  execution. 

The  followiiig  case  sJwws  a  combination  of  purulent  cholecystitis 
with  obstruction  of  the  choledochus  by  a  stone. 

Mrs.  A.,  29  years,  wife  of  a  merchant,  from  Liideritz  (Alt- 
mark).  Entered,  29.  4.  99.  Oper.,  i.  5.  99.  Cystectomy. 
Hepaticus  drainage.      Still  under  treatment. 

Amnesis. — Parents  of  the  patient  are  living  in  good  health, 
likewise  8  brothers  and  sisters.  Mrs.  A.  married  at  20  years, 
mother  of  3  healthy  children,  2  are  dead.  Until  1893  the 
patient  had  nothing  to  do  with  sickness  ;  suddenly  in  the  even- 
ing she  was  taken  with  a  cramp  in  the  stomach  of  great  vio- 
lence ;  it  lasted  2  hours,  and  ended  with  vomiting.  In  8-day 
intervals  the  attacks  recurred  for  3  months.  January,  1894,  a 
physician  ordered  powder  and  Carlsbad  salts.  Afterwards  two 
years  of  good  health  ;  no  distress  of  the  stomach.  The  less 
severe  attacks,  about  twice  in  the  year  1896.  1897,  also  two 
attacks.  1898,  attack  in  February,  then  seven  weeks  Carlsbad 
cure  at  home.  End  of  February,  1899,  new  attack  of  the  char- 
acter of  the  former  ones,  very  severe,  but  not  attended  by  vomit- 
ing. Since  then  right-sided  pains,  some  stomach  pains,  eructa- 
tions. In  March,  chills,  then  violent  pains  in  the  right  upper 
side  of  the  abdomen.  End  of  March,  cramp  in  the  stomach 
and  chill  ;  8  days  later  the  same,  then  slight  jaundice.  A  week 
long,  twice  daily,  cramp  of  several  hours'  duration.  Then  re- 
ception into  the  clinic  here.  Recently  the  woman  has  lost  flesh 
(about  5  kilos)  in  consequence  of  miserable  appetite. 

Status  Prsesens. — Medium-sized,  strong  woman  ;  slightly  ic- 
teric. Liver  not  enlarged  ;  in  the  region  of  gall-bladder  a  tumor 
of  the  size  of  a  goose  ^^'g,  hard,  painful  and  but  little  movable, 
which  extends  below  the  navel.  In  the  urine  no  albumin  or 
sugar,  some  bile  pigment.      Lungs,  heart,  etc.,  healthy. 

Diagnosis. — Cholecystitis  probably  purulent,  pericholecystitis 
adhesiva  (omentum  and  stomach),  small  and  large  stones  in  the 
gall-bladder,  lithogenous  occlusion  of  the  cysticus,  inflammatory 


APPENDIX.  359 

jaundice  probable,  yet  a  stone  in  the  supra-duodenal  part  of  the 
choledochus  not  to  be  excluded. 

Operation,  i.  5.  99.  Longitudinal  incision  in  the  right  rectus 
abdominal  muscle.  Omentum  adherent  to  the  parietal  perito- 
neum, covering  completely  the  gall-bladder.  The  tumor  felt 
was  the  gall-bladder  covered  with  omentum.  No  enlargement 
of  the  liver.  On  separation  one  opens  into  a  cavity  in  which  2 
stones  are  lying,  which  have  broken  through  the  gall-bladder 
into  the  abdominal  cavity,  and  have  imbedded  themselves  in  the 
omentum.  The  gall-bladder  is  exposed  with  difficulty.  In  the 
cysticus  many  stones.  Removal  of  the  rotten,  perforated  gall- 
bladder. In  the  choledochus,  which  is  easy  to  sound  from  the 
transverse  section  of  the  cysticus,  one  clearly  feels  with  the 
sound  a  stone  ;  it  is  lodged  immediately  in  front  of  the  papilla 
of  the  duodenum.  Later  it  disappeared  in  the  attempt  to  press 
it  upwards  ;  perhaps  it  was  squeezed  into  the  duodenum.  On 
sounding  the  hepaticus  one  struck  a  second  stone,  which  was 
easily  removed.  Drainage  of  the  hepaticus  since  muddy  bile 
escaped.  The  choledochus,  which  was  slit  up  from  the  cysticus 
to  the  duodenum,  was  sutured  with  catgut.  Tampon  around  the 
tube  with  sterile  gauze.  The  omentum,  so  far  as  it  was  patho- 
logical, was  amputated.  Stump  dropped.  Closure  of  the  ab- 
dominal wall  with  through  and  through  silk  sutures.  Tampon 
brought  out  the  upper  angle  of  the  wound.  Difficult  i  ^-hour 
operation.      18  stones  in  the  gall-bladder. 

Course  was  completely  afebile.  From  the  tube  escaped  daily 
about  300  gr.  of  bile.  Removal  on  the  14th  day  of  all  gauze. 
Since  then  the  dressings  were  dry.     Excellent  general  condition. 

Remarks. — The  patient  had  passed  through  a  sero-purulent 
cholecystitis.  It  came  to  perforation ;  happily  the  omentum 
hindered  the  extension  of  the  peritonitis.  The  gall-bladder 
communicated  through  a  hole  with  the  intra-peritoneal  cavity, 
which  had  formed  in  the  omentum,  and  contained  2  stones.  Al- 
though marked  icterus  existed  at  the  time,  still  a  stone  lay  in  the 
hepaticus.     Whoever   in  such  a  case  neglects   to   open  up  the 


360  GALLSTONE  DISEASE. 

choledochus  and  to  sound  the  hepaticus,  is  readily  inclined  to 
assume  inflammatory  jaundice,  although  a  lithogenous  jaundice 
exists. 

The  son-in-law  of  the  patient,  Dr.  Gilbert  of  Derne,  had 
made  the  correct  diagnosis  and  determined  the  indication  ;  an- 
other physician  was  against  the  operation  :  '*  It  is  too  danger- 
ous!" To  wait  in  such  a  case  is  more  dangerous,  however,  than 
to  operate.  Many  times  in  such  cases  operations  in  2  stages 
are  still  done.  Then  stones  remain  in  the  hepaticus,  and  the 
internal  physicians  rightly  cry  :  "  The  operation  has  been  of  no 
use;  the  stones  return."  If,  on  the  whole,  one  operates,  then 
he  ought,  if  it  is  in  any  way  possible,  to  thoroughly  expose  all 
the  ducts,  palpate  and  sound  them.  Every  surgeon  ought  to  be 
careful,  but  not  timid  or  anxious  ;  especially  in  gallstone  opera- 
tions is  dawdling  an  evil.  "  Promptly  tried  is  half  won  !"  I 
have  become  in  recent  times  much  more  active,  and  observe 
even  as  little  ceremony  with  the  hepaticus  as  with  the  gall-blad- 
der ;  my  results  have  in  consequence  become  constantly  better. 

The  following  case  is  in  respect  to  diagnosis  an  extremely  in- 
structive case  of  melasicterus  : 

F.  M.,  44  years,  from  X.  Entered,  19.  4.  99.  Operation,  25. 
4.  99.  Hepaticus  drainage.  Discharged,  2.  5.  99.  Dead  of 
pneumonia. 

Amnesis. — Father  died  of  phthisis.  Mother  of  a  heart  dis- 
ease after  that  she  was  ill  for  a  long  time  with  liver  and  lung 
disease.  Patient  as  a  child  suffered  from  malarial  fever  with  en- 
largement of  the  spleen  ;  as  a  young  girl  she  had  for  years  to 
contend  against  anaemia  and  cough.  She  is  the  mother  of  3 
healthy  children;  about  7  years  ago  she  aborted  after  2^ 
months  pregnancy.  The  succeeding  years  profuse  uterine 
haemorrhage  ;  despite  this  a  short  time  later  another  pregnancy, 
in  the  course  of  which  haemorrhage  frequently  occurred.  To- 
ward the  end  of  pregnancy  an  operation  for  a  sarcoma  of  the 
lower  jaw,  on  the  same  day  (normal)  delivery  without  compli- 
cations.     In   the   summer  of  1897,  after  a  cold   bath,  there  oc- 


I 


APPENDIX.  361 

curred  an  extremely  painful  attack  ;  the  pains  were  located  es- 
pecially in  the  region  of  the  stomach  and  radiated  toward  the 
chest  ;  jaundice  and  vomiting  did  not  appear.  The  attack  lasted 
only  a  few  minutes.  In  November  of  the  same  year  again  a 
similar  attack,  which  the  patient  designated  as  cramp  of  stomach. 
The  pains  were  again  located  in  the  stomach  and  radiated  to- 
ward the  back  and  chest.  A  few  days  afterwards  the  patient 
noticed  a  gradually  deepening  jaundice,  the  urine  was  dark 
brown,  almost  black  ;  patient  was  treated  by  her  physician  with 
purgatives  without  success.  Stools  were  colorless,  patient  was 
very  weak  and  complained  greatly  of  the  itching  of  the  skin. 
Three  weeks  after  the  beginning  of  the  icterus  the  menstruation 
ceased.  Four  weeks  later  the  feet  swelled,  several  weeks  later 
the  abdomen  also,  and  a  gynaecologist  diagnosticated  ''  ulcer  of 
the  uterus."  The  swelling  of  the  legs  and  the  abdomen  disap- 
peared after  hot  baths.  February,  1898,  in  the  hospital  at  Han- 
nover, gallstones  were  diagnosticated  as  the  cause  of  the  icterus, 
which  remained  almost  the  same.  Patient  used  many  sorts  of 
domestic  remedies,  drank  Muhlbrunn,  was  from  August  to  the 
beginning  of  November  in  Carlsbad  ;  here  the  jaundice  quite 
noticeably  abated,  the  general  condition  improved  markedly. 
Patient  feels  decidedly  better.  At  home  she  still  continued  the 
cure  a  couple  of  weeks,  then  she  fell  ill  with  nervousness  and 
pleurisy,  laryngeal  catarrh,  and  was  treated  with  all  possible 
means.  The  jaundice  slowly  increased  again,  the  stools  were 
putty-like,  the  urine  darker.  From  time  to  time  fever  occurred 
in  the  evening,  in  the  night  profuse  sweats  broke  out  and  the  pa- 
tient became  weaker.  At  present  the  patient  complains  of  pains 
in  the  region  of  the  liver,  which  especially  occur  after  move- 
ment, of  very  intense  jaundice,  and  at  times  of  torturing  flatu- 
lence ;  moreover,  the  patient  says  that  some  years  ago  she  was 
operated  upon  for  sarcoma  of  the  lower  jaw,  and  had  also  got 
lues,  and  for  it  had  been  treated  with  inunctions  and  iodide  of 
potassium. 

Status  Prsesens. — Liver  enlarged,   lower  border  reaches  to 


362  GALLSTONE  DISEASE. 

the  navel.  Spleen  palpable.  No  ascites.  Surface  of  the  liver 
smooth.  Melasicterus.  Patient  looks  like  a  mulatto.  Heart 
and  lungs  normal,  in  the  urine  much  bile  pigment,  no  albumin 
or  sugar. 

Diagnosis. — Choledochus  occlusion  by  cicatrix.  Stones  im- 
probable.     Lues?     Sarcoma? 

Operation,  25.  4.  Schleich's  local  anaesthesia  was  tried,  but 
the  patient  complained  so  much  that  chloroform  anaesthesia  was 
induced.  Hook-incision  of  Czerny.  Liver  large,  very  firm,  sur- 
face smooth,  no  knobs  or  contractions.  Gall-bladder  con- 
tracted, empty,  adherent  to  the  colon  and  stomach,  separation. 
The  ligamentum  hepato-duodenale  was  exposed.  It  becomes  evi- 
dent that  there  is  in  the  hepaticus  about  2  cm.  above  the  open- 
ing of  the  cysticus  a  hard  spot,  which  is  similar  to  a  stone.  Ex- 
posure of  this  place.  Licision  upon  the  hardness,  no  stone,  but 
a  firm  scar.  With  great  difficulty  one  succeeds  in  passing  a  fine 
probe  into  the  hepaticus,  immediately  escapes  into  the  under- 
lying napkins  bile  looking  like  soap-water.  Division  of  the 
stricture  with  blunt  bistour}^  Introduction  of  the  glass  tip  of 
the  irrigator  tube.  Tampon  of  the  whole  porta  hepatica.  A 
haemostat  is  left  upon  a  sharply  bleeding  vein.  Suture  of  the 
abdominal  wound.  The  intention  to  establish  a  communication 
between  the  opening  in  the  hepaticus  and  the  gall-bladder,  that 
is  to  make  a  hepatico-cystostomy,  in  order  later  to  execute  a 
cholecystenterostomy,  was  temporarily  given  up,  since  the  patient 
was  very  much  collapsed  and  could  scarcely  bear  a  further  pro- 
longed operation. 

Course. — From  25-27.  4.  early  no  fever,  slight  vomiting. 
Flatus  passed  after  glycerine  enemata.  On  the  28.  4.  change  of 
dressings,  since  only  a  little  blood  escaped  from  the  tube,  but  no 
bile.  After  the  removal  of  the  gauze  tampon  and  the  Pean's 
haemostat  it  was  evident  that  the  tube  in  the  hepaticus  was 
plugged  by  blood  clot.  New  tampon,  without  that  one  drained 
the  hepaticus  anew  ;  with  the  tendency  to  cholaemic  bleeding  it 
did   not  seem  to  me  proper.      Dressing.     Profuse  flow  of  bile 


APPENDIX.  363 

from  the  tampon.  On  the  evening  of  the  27.  4.,  39.0°  C.  ;  pulse, 
140.  Flatus  passes  spontaneously.  In  the  right  lower  lobe 
pneumonia.  28.  4.,  morning,  38.5°  C. ;  130  strong  pulse.  Up 
till  I.  5.  fair  condition.  Then  rapid  failure  of  strength.  Died, 
2.  5.  99.      No  autopsy. 

Remarks. — The  stricture  of  hepaticus  may  have  been  of  in- 
flammatory nature ;  possibly  it  is  to  be  ascribed  to  syphilis. 
Although  the  case  is  not  completely  explained,  I  assume,  since 
several  physicians  who  had  formerly  treated  the  patient  were  of 
the  opinion  that  there  had  been  gallstones,  and  since  the  attend- 
ing physician  in  Carlsbad  had  prescribed  as  of  value  to  the  pa- 
tient a  renewed  cure  in  Carlsbad.  Carlsbad  in  this  case  of  com- 
plete occlusion  of  the  hepaticus  could  be  of  absolutely  no  ser- 
vice. If  the  wards  of  a  key  are  broken  in  a  lock,  then  one  does 
not  pour  oil  in  it,  but  takes  the  lock  apart,  and  if  the  common 
bile  duct  is  by  a  mechanical  obstacle  occluded,  then  neither  oil 
nor  Sprudel  is  of  service  ;  then  the  knife  must  be  taken  up,  and 
indeed  not  so  late  as  in  this  case.  If  a  pneumonia  had  not  oc- 
curred the  patient  would  perhaps  have  come  through  the  opera- 
tion ;  at  least  on  the  side  of  the  abdomen  no  reaction  had  oc- 
curred, the  bile  escaped  freely  and  the  tampon  had  brought 
about  a  satisfactory  shutting  off  of  the  abdominal  cavity.  I  had 
been  able  after  an  examination  of  several  days  to  explain  to  her 
husband  that  everything  spoke  against  an  occlusion  by  stone. 
(The  intense  pain,  the  unchanging  character  of  the  feces,  the 
absence  of  colics.)  Since  lues  and  sarcoma  had  preceded,  the 
assumption  was  natural  that  the  cause  of  the  choledochus  occlu- 
sion was  to  be  sought  in  these  diseases.  The  stricture  of  the 
hepaticus  upon  which  I  chanced  was  quite  long  and  firm,  so 
that  without  operation  a  fatal  result  would  in  a  short  time 
have  occurred.  I  had  declared  to  the  husband  that  without 
operation  death  was  certain,  but  that  interference  might  be  fol- 
lowed by  serious  dangers  (bleeding  and  pneumonia),  and  the 
danger  must  be  estimated  at  50  per  cent.  Since  he  saw  that 
without  operation  a  rescue  was  impossible,  he  gave  his  assent  to 


364  GALLSTONE  DISEASE. 

it.  That  the  enfeebled  organization  did  not  withstand  the  inter- 
ference is  not  to  be  wondered  at. 

In  the  following  case  we  had  to  do  luith  a  carcinoma  in  the  gall- 
bladder luith  implication  of  the  porta  hepatitis. 

M.  B.,  widow,  capitaHst,  from  Halberstadt,  61  years.  Entered, 
12.  4.  99.  Operation,  15.  4.  99.  Liver  and  gall-bladder  car- 
cinoma.     Exploratory  incision,  17.  4.  99.      Died  of  cholaemia. 

Amnesis. — Family  history  unimportant.  Patient,  mother  of 
7  children,  had  30  years  ago  suffered  from  catarrh  of  the  stom- 
ach with  slight  jaundice,  otherwise  she  has  been  in  good  health 
until  her  present  illness.  In  the  autumn  of  the  previous  year 
she  was  taken  ill  with  disturbance  of  digestion,  loss  of  appetite, 
feeling  of  fullness  after  eating,  constipation,  pressing  pain  in  the 
region  of  the  stomach  and  liver.  In  the  beginning  of  the  year 
her  stools  lost  their  color,  the  urine  became  beer-brown,  and 
gradually  there  developed  an  increasing  jaundice.  Patient  lost 
a  great  deal  of  flesh  and  became  weaker  from  day  to  day. 
Several  weeks  ago  twice  epistaxis  ;  with  the  epistaxis  usually 
itching  of  the  skin  occurred.  Stools  remained  permanently 
discolored.      Fever  never  occurred. 

Status  Prsesens — Intensely  icteric,  yet  moderately-nourished 
woman.  Heart  and  lungs  sound.  Pulse  small,  66.  Tongue 
furred.  The  liver  extends  an  av^erage  2  or  3  finger-breadths 
beyond  the  ribs,  feels  rough  or  hobnailed,  and  is  moderately 
sensitive  to  pressure.  Enlargement  upward  not  demonstrable. 
Besides  nothing  especial  in  the  abdominal  organs.  No  demon- 
strable dilatation  of  the  stomach,  no  ascites.  No  enlargement 
of  the  glands.  Urine  :  traces  of  albumin,  considerable  bile  pig- 
ment, no  sugar.  Stools  putty-colored,  hard  and  constipated. 
Dr.  Spiller  advised  operation.  Patient  declared  subsequently 
that  she  had  had  before  her  present  illness  several  typical  attacks 
of  colic,  the  first  about  23  years  ago,  the  second  about  15,  the 
third  about  7  years  ago,  that  is  3  attacks  at  very  long  intervals. 

Diagnosis. — Chronic  occlusion  of  the  choledochus  by  stone, 
at  all  events  carcinoma. 


APPENDIX.  365 

It  is  not  certainly  to  be  decided  whether  the  irregularities  felt 
on  the  liver  border  belong  to  the  liver  itself  or  are  only  simulated 
in  that  one  presses  during  palpation  against  the  liver  the  in  part 
shrunken  and  wasted  subcutaneous  fat. 

Operation,  15.  4.  99.  Longitudinal  incision  in  the  right  rectus 
abdominal  muscle.  Liver  over  the  gall-bladder  very  hard  and 
cicatricially  contracted.  Closer  examination  discloses  carcinoma, 
in  the  choledochus  many  hard  places.  On  this  account  closure 
of  the  abdominal  cavity. 

Patient  received  the  last  kw  days  before  operation  3  times  a 
day  1.8  grm.  calcium  chloride  (Mayo-Robson  to  counteract 
chohemic  bleeding),  and  after  it  3.6  grms.  as  enemata. 

Course. — No  fever.  In  the  first  twenty-four  hours  vomiting 
of  bile.  After  outwashing  of  the  stomach  this  ceased.  Patient 
falls  into  a  comatose  condition,  belly  soft,  flatus  passes  spon- 
taneously, no  vomiting.  It  was  positively  coma  cholaemicum. 
Patient  died  on  17.  4  in  the  evening.      No  autopsy. 

If  I  still  once  again  review  the  work  of  the  last  8  weeks  in 
which  I  have  24  times  employed  the  knife  by  reason  of  chole- 
lithiasis, I  must  then  admit  that  I  have  still  in  respect  to  diagnosis 
learned  a  great  deal  which  was  until  then  unknown.  In  respect 
to  technique  I  have  come  to  the  opinion  t/iat  tJie  gallstojic  sur- 
geon cannot  proceed  too  actively.  If  one  establishes  the  indication 
for  operation,  then  one  should  so  proceed  that  one  informs  him- 
self as  thoroughly  regarding  the  contents  of  the  cysticus  and 
choledochus  as  of  the  gall-bladder.  The  permanent  results — 
and  upon  these  alone  it  all  hinges — depend  solely  from  this,  that 
one  does  not  fear  even  as  thoroughly  to  palpate  and  open  up  the 
hepaticus  and  choledochus  as  the  gall-bladder  and  cystic  duct. 
I  know  very  well  that  other  surgeons  are  in  this  respect  to  me 
of  opposite  opinion,  but  I  am  convinced  that  they,  if  they  have 
the  same  experience  as  I,  will  come  to  the  same  way  of  thinking. 

*'  Either  operate  thoroughly  or  not  at  all  ;"  that  is  the  principle 
to  which  I  to-day  swear  homage  upon  the  ground  of  433  gall- 
stone laparotomies. 


NDEX. 


Acute  obstruction    of  common    duct   by 

stone,  86  ;  Group  IX.,  230 
Adhesions  as  a  cause  of  colic,  37,  124 
to  stomach    as    a    cause  of  stomach 

troubles,  37 
to  duodenum  and  intestine  the  cause 

of  alternating  diarrhtea,  55 
trouble   from   after  successful  opera- 
tions, 105,  124 
Age  at  which  gallstones  appear,  52 
Amnesis,  the  very  great  importance  of  an 
exact,  50 
points  to  be  observed  in  the,  52,  57 
Anaesthetics  in  diagnosis  of  litde  value,  64 
Appendicitis   or   cholecystitis?    72,    188, 
190,  191 


Biliary  fistula,  closure  of,  209,  215,  221 
Blood  examination  in  gallstone  disease,  65 
Boas'  point  not  regarded  by  Kehr  as  of 
value  in  the  diagnosis  of  gallstones,  71 
Breathing,  type  of  in  the  differential  diag- 
nosis between  peritonitis  and  gallstones, 

74 
Button,   Murphy's,   in   resection  of  intes- 
tine, 141 

Calcium    chloride  for  cholpemic  haemorr- 
hage, 365 
Carlsbad  cure,  cases  for,  114 
Carcinoma  of  gall-bladder,  two  forms  of, 

46,  225,  226,  228  ;  Group  IX.,  86 
Cholelithiasis,  special  diagnosis  of,  67 

intrahepatic,  97 

dangers  of,  107 

fever  in,  81 

icterus  in,  82 

enlargement  of  liver  in,  82 

enlargement  of  spleen  in,  82 

albumin  in  urine  in,  82 

and  right-sided  movable  kidney,  212 

and  right-sided  hydronephrosis,  216 

and  prolapse  of  liver,  2 1 7 
Cholecystitis,  acute  serous,  179 

acute,  in  contracted  gall-bladder,  196  ; 
Group  v.,  85 


Cholecystitis,   acute,   in  relatively  slightly 
altered    distensible   gall-blad- 
der, 169;  Group  IV.,  84 
sero-purulent,  surgical  treatment 
of,  121 
relieved  by  Carlsbad  cure,  but  stones 

not  expelled  or  dissolved,  loi 
with  chronic  pancreatitis,  193 
with  right-sided  hydronephrosis,  215 
with  right-sided  movable  kidney,  214, 
217 
Cholecysto-enterostomy,  274,  282 

colostomy,  274 
Choledochus,    chronic    obstruction   of  by 
stone,   231  ;    Group  X.    and   XL, 
86 
chronic  obstruction  of  by  tumor,  273  ; 

Group  XII.,  86 
differential  diagnosis  of  chronic   ob- 
struction of  by  stone  or  tumor,  90, 
91 
chronic      recurring     obstruction    of, 

129 
danger  of  dawdling  in  obstruction  of, 
129 
Choledochotomy,  results  of,  135 
importance  of  drainage  in,  245 
cases  of,  214,   231,    234,   236,   237, 
241,  243,  251,  254,  256,  257,  259, 
264,  268,  276,  281,  282,  292,  350, 
356 
Choledocho-duodenostomy,  281,  284 

enterostomy,  2S4 
Cholagogue  treatment  of  gallstones,  1 00 
Cholangids,  drainage  and  tampon  in,  335 
Cirrhosis,  biliary,  284 
Classification  of  gallstone  disease,  97 
Clinical    histories    illustrating    differential 

diagnosis,  135  and  following 
Contraction  of  gall-bladder  from  repeated 

attacks  of  inflammation,  38 
Colic,  gall-bladder,  of  mechanical  nature, 

317 
Colics  due  almost  always  to  inflammation 
of  the  gall-bladder,  29,  47 
character  of  gallstone,  82 
due  to  adhesions,  1 59 

(367) 


368 


INDEX. 


Colics,  pancreatitic,  77 
renal,  74 

non-existence  of  a  liver,  of  nervous 
origin,  74 
Cramps,    majority   of    stomach    are    gall- 
stone colics,  72 
Cystectomy,  203,  214,  217,  237,  243,  251, 
254,  256,  264,  266,  268,  279,  284, 
290,  292,  298,  301,  302,  303,  305, 
306,  312,  313,  316,  319,  322,  324, 
326,  337,  340,  342,  343,  346,  350, 
356,  35« 
atypical,  220 
results  of,  135 
Cysticotomy,    204,    206,    208,   212,    251, 
257,  294,  343 
secondar}^,  170,  171,  199,  253 
Cystico  lithotripsy,  210,  211 
duodenostomy,  167 
gastrostomy,  195 
Cystendesis,  336 
Cysto-gastrostomy,  354 
Cystopexy,  317 

Cystostoray,  204,  206,  208,  212,  215,  221, 
223,  231,  236,  241,  253,  257,  288, 
294,  295 
slight  danger  of,  333 
in  two  stages,  210 

Dangers  of  cholelithiasis  not  appreciated 

by  the  laity,  107 
Diagnosis,  differential,  of  gallstones,  84 

between  dropsy  and  empyema  of 

gall-bladder  and  cancer,  92 
chronic    obstruction    of    chole- 
dochus  by  stone  and  by  tumor, 
90,  91 
gall-bladder   and  movable  kid- 
ney, 81 
gall-bladder  and  other  tumors,  79 
stone     in     common     duct    and 
tumor,  91 
Diarrhoea,  alternating  with  constipation,  a 

symptom  of  adhesions,  55 
Difficulty    and    impossibility    of    special 
diagnoses  in  certain  cases,  clinical  his- 
tories, 311 
Diverticulum  of  gall-bladder,  206 
Dilatation,  acute,  of  stomach,  250 
Distress  after  operation   from   adhesions. 

Drainage  of  hepaticus  and  choledochus  a 
safeguard   against  leaving  stones  **  so- 
called "  recurrences,  105 
Dropsy  of    gall-bladder  an   end  product 
of  an  infective  inflammation,  32 
chronic,  of  gall-bladder,  204 


Empyema  chronicum  cystidis  feller,  220  ; 
Group  VII.,  85 

origin  of,  38 
Enteroptosis  a  cause  of  colics,  151 
Examination,  anaesthetics  in,  64 

of  feces,  58 

of  gallstone  cases,  57,  64 
Entero-enterostomy,  313 
Exploratory  puncture  of  gall-bladder  dan- 
gerous, 64 

incision,  282,  284,  286,  364 

Feces,  examination  of  important,  58 
Fistul??  of  gall-bladder,  94,  264 

and  stomach,  closure  of,  245 
Frequency  of  gallstones,  25 

Gall  bladder  cases,  no  two  alike,  48 
cancer  of,  two  forms,  46 

frequency  of,  46 
enlargements  of,  77 
differentiation  of  tumors  of  the,  79 
dropsy  of  the,  32 
serous  inflammations  of,  spontaneously 

curable,  31 
diphtheritic  and  phlegmonous  inflam- 
mation of,  31 
condition    of,     after     subsidence    of 

cholecystitis,  33 
usually  not  enlarged  in  obstruction  of 

common  duct  by  stone,  62 
usually  a  palpable  tumor  in  chronic 
obstruction  of  the  common  duct  by 
tumor,  62 
Gallstone   cases   furnish    14  per  cent,    of 
cases  of  cancer,  46 
disease,  frequency  of,  99 
latency  of,  99 
dangers  of,  36 
ileus,  308 
Gallstones  rarely  cause  a  single  attack  of 
colic,  35 
found  in  87.5  per  cent,  of  the  cases 
of  cancer  of  liver  and  gall  blad- 
der, 46 
Gastric    cases   of    locomotor   ataxia    and 

gallstone  colic,  75 
Gland,  Virchow's,  a  symptom  of  cancer,  92 
Gastro-enterostomies,  195,  245,  302,303, 

305,  31 !»  348 
Gaslro-enterostomy,    combined  with  cys- 
tico-gastro-enterostomy,  195 

Hepatopexy,  217,  243,  251,  257,  290,  324 
Hepaticotomy,  337 

Hernia  of  linea  alba  mistaken   for  gall- 
stones, 75,  348 


INDEX. 


369 


Hepatic  duct,  drainage  of,  245,  264,  266, 

268,  276,  279,  290,  340,  350,  358,  360 

Hydrops   chronicus   cystidis   felleai,  204 ; 

Group  VI.,  85 

of  gall-bladder,   best   explained  by  a 

quickly  passing  infection  of  slight 

degree,  32 

Ileus-like  symptoms,  185,  188 
Indications  for  a  Carlsbad  cure,  1 14 

for  operation  in  morphinism,  etc.,  56, 
130 
in  dilated  stomach  and  hypertro- 

phied  pylorus,  1 26 
in  chronic  recurring  cholecystitis, 

128 
in  abscess  of  liver  and  subphrenic 

abscess,  130 
in  suppurative  processes  in   ab- 
domen, 122 
opposite  views  of  von  Winiwar- 
ter and  Kraus  regarding,  102 
social  side  of,  122 
Inflammation,  usually  of  infectious  origin 
and  of  varying  degree,  29 
the  active  agent   in    changing   gall- 
stones  from  a  latent  to   an  active 
condition,  26 
Intestine,  resection  of,  I41 
Irregular  forms  of  gallstone  disease  (Rie- 
del),  40,  108 

Jaundice  absent  in  80  per  cent,  of  gall- 
stone cases,  88 
in  cholecystitis  only  when  inflamma- 
tion has  extended  to  the  cystic  and 
common  ducts,  40,  88 
akathektic  or  functional,  41,  332 
Leichtenstern  on  functional,  41 
E.  Pick  on  functional,  41,  42 
inflammatory,  Kehr  on,  330,  337 
variable  with  choledochus  stone,  44, 

.    ^9 

inflammatory  or  lithogenous  ?  288 

Kehr's  contributions  to  gallstone  surgery 
and  pathology,  23,  note 
criticism  of  Riedel's   views  of  para- 
lienitis  infectosa,  3^3,  334 
Kidney,  movable,  151,  214,  217 

differential  diagnosis  between  tumor 
of  the  gall-bladder  and  movable 
kidney,  80 

Latency  of  gallstones,  25 

changed  into  activity  by  inflam- 
mation,  26 


Leichtenstern    on    threatened   perforation 
and  its  treatment,  i  23 
on  functional  jaundice,  41 
Linea  alba,  hernia  of,  mistaken  for  gall- 
stones, 75 
Liver,  enlargement  of,  almost  always  ab- 
sent in  cholecystitis,  39 
uncommon  in   chronic    obstruc- 
tion of  common  duct  by  stone, 

colic,  of  nervous  origin,  not  believed 
in  by  Kehr,  74 
Lobe  of  Riedel  in  cholecystitis,  39 
Lymphatic  glands  of  cystic  and  common 
ducts,  swelling  of  the  result  of  chole- 
cystitis, 37 

Morphinism  as  an  indication  for  opera- 
tion, 56,    130 

Mucous  membrane  of  gall-bladder  an  in- 
dex of  the  degree  of  infection,  30 

Naunyn,  on  the  theory  of  gallstone  colic, 
26,  27 

on  the  infectious  origin  of  cholecys- 
titis, 30 

on  the  prognosis  of  gallstones,  109 

Obstruction,    acute,   of    choledochus    by 
stone,  230 
chronic,  of  choledochus  by  stone,  231 
Operation,  what  constitutes  early?   106 
imperative,  1 1 5 
preventive  for  gallstones,  141 
results  of,  for  gallstones,  135 
in  two  stages  likely  to  overlook  stones 
in  the  cystic  and  common  ducts,  105 
Overlooking  stones  a  matter  of  experience 
largely,  105,  170,  171,  172,  177 

Pancreas  as  related  to  gallstone  disease,  76 
Pancreatitis  interstitialis,  43 

chronic,  with  cholecystitis,  193 
Paracholia  of  E.  Pick,  41 
Palpation,  the  great  value  of  in  diagnosis, 
60 

method  of,  60,  61 

bimanual  method  of,  61 
Pericholecystitis,  36,  182 
Pain  of  cholelithiasis,  67,  68,  69 

character  of  in  the  differential  diag- 
nosis between  gallstones  and  ulcer 
ventriculi,  69 

girdle,  234 

sacral,  161,  234 

oesophageal,  344 

rectal,  246,  260 


370 


INDEX. 


Passage  of  stones  less  common  than  sup-  ' 
posed,  88  i 

Pathology  of  gallstone    disease,    the    im- 
portance of,  19,  20 
and  its  study  on  the  living,  20, 
21 
Perialienitis  infectosa  choledochi,  334 
tamponade  in,  335 
serosa  (Riedel's  foreign  body  inflam- 
mation), 28 
with  suture,  272 
Percussion  in  the  examination  of  gallstone 

cases,  63 
Peristalsis   of  bowel   not   rarely  becomes 
reversed   in    region    of    inflamed    gall- 
bladder, 60 
Perforations  of  gall-bladder   the  result  of 

empyema,  38 
Peritonitis,  differential  diagnosis  between 
peritonitis  and  gallstones  vide  breathing, 

74 
diffuse,  the  result  of  cholecystitis,  184 
Preventive  operation  for  gallstones,  141 
Prognosis,   contradictory  views    concern- 
ing,  by  internists    and    surgeons, 
III 
Naunyn's  views  concerning,  no 
Fiirbringer' s  views  concerning,  109 
Pyloroplasty,  301,  306,  312,  346 

Recurrence  of  gall.-itones  from  sutures,  105 

Renal  colic  and  its  differentiation  from 
gallstone  colic,  74 

Respiration,  movement  with,  as  a  differ- 
ential factor  between  enlarged  gall- 
bladder and  tumors  of  colon,  pancreas, 
etc.,  80 

Resume  of  important  factors  in  diagnosis, 
88 

Ribs,  resection  of  (Lannelongue )  in  gall- 
stone operation,  224 

Riedel  does  not  tampon  after  choledochot- 
omy,  245 

Riedel's  theory  of  foreign  body  inflamma- 
tion as  cause  of  colic,  28 
irregular  forms  of  gallstone  disease, 

40 
lobe  in  cholecystitis,  39,  174,  181 

Rose's  method  of  clearing  out  the  cystic 
duct,  etc.,  from  the  opening  in  the  gall- 
bladder, 357 

Solvents  of  gallstones  do  not  exist,  100 
Soft    gall-bladder    (non-palpable)    means  i 
patent  cystic  duct,  144  ( 


Stomach,  acute  dilatation  of,  250 

or  gall-bladder,  or  both  affected,  293 
Stones  in  an  unaltered  or  slightly  altered 
gall-bladder,  84,  Group  I. 
in    an    unaltered    or   slightly  altered 
gall-bladder,  clinical  histories,  141 
in    the    already    frequently    inflamed 
gall-bladder,  cystic  duct  at  present 
patent,  contents  pure  or  but  slightly 
changed  bile,  adhesions,  84,  Group 
II. 
in    the    already    frequently   inflamed 
gall-bladder,  cystic  duct  at  present 
patent,  contents  pure  or  but  slightly 
changed   bile,    adhesions,    clinical 
histories,  150 
absent  from  gall-bladder,  cystic  duct 
patent,    contents  pure  bile,    adhe- 
sions, 84,  Group  III. 
absent  from  gall-bladder,  cystic  duct 
patent,    contents  pure  bile,    adhe- 
sions,  clinical  histories,  159 
Stools,  examination  of,  58 
Sugar  not  often   found   by  Kehr  in   the 
urine  of  gallstone  cases,  57 
Czerny's  experience  the  contrary,  57 
Sutures  a  cause  of  the  reformation  of  gall- 
stones, 105 
Swelling   of  the  lymphatic  glands  upon 
cystic  and  common  ducts  may  simulate 
stones,  37 
S}'philis  simulating  cholecystitis,  75 

Table  for  differential  diagnosis,  84  et  seq. 
Tarrying  of  stones  in   the   common   duct 

and  hepaticus,  354 
Trauma,  effect  of  in  changing  cholelithiasis 

from   a   latent  to   an   active  condition. 


223,  225 
Treatment  of  gallstones  confined  to  Carls- 
bad cure  or  operation,  99 
by  cholagogues,  100 
expectant,  129 
Tubercular  peritonitis,  321,  322 

Ulcus  ventriculi,  348 

Urine,  sugar  in,  infrequent  (Kehr),  57 

frequent  (Czerny),  57 
"  Unsuccessful  "  attacks  of  colic  (Riedel), 

frequency  of,  40 
Use  of  calcium  chloride  to  prevent  cholae- 

mic  bleeding,  365 

Virchow's  gland  as  a  symptom  of  cancer, 
92 


A  Classified  Catalogue  of 
Books  on  Medicine  and  the 
Collateral  Sciences,  Phar- 
macy, Dentistry,  Chemistry, 
Hygiene,    Microscopy,    Etc, 


«^ 


P.  Blakiston's  Son  &  Company,  Pub- 
lishers of  Medical  and  Scientific  Books, 
IOI2    Walnut    Street,    Philadelphia 

No.  8.    2-24-02. 


SUBJECT    INDEX 


Special  Catalogues  of  Books  on  Pharmacy,  Dentistry, 
Chemistry,  Hygiene,  and  Nursing  will  be  sent  free  upon 
application.  All  inquiries  regarding  prices,  dates  of  edition, 
terms,  etc.,  will  receive  prompt  attention. 


SUBJECT  PAGE 

Alimentary  Canal(seeSurgeiy)  19 

Anatomy 3 

Anesthetics 14 

Autopsies  (see  Pathology) 16 

Bacteriology  (see  Pathology)..  16 

Bandaging  (see  Surgery) 19 

Blood,  Examination  of 16 

Brain  4 

Chemistry.      Physics 4 

Children,  Diseases  of 6 

Climatology 14 

Clinical  Charts 20 

Compends 22,  23 

Consumption  (see  Lungs) 11 

Cyclopedia  of  Medicine 8 

Dentistry 7 

Diabetes  (see  Urin.  Organs)..  21 

Diagnosis 6 

Diagrams  (see  Anatomy) 3 

Dictionaries,  Cyclopedias. 8 

Diet  and  Food 14 

Dissectors 3 

Ear 9 

Electricity  9 

Embr^'ology 3 

Emergencies 19 

Eye 9 

Fevers 9 

Food 14 

Formularies  16 

Gynecology  21 

Hay  Fever 20 

Heart 10 

Histology 10 

Hydrotherapy 14 

Hygiene 11 

Hypnotism 14 

Insanity  4 

Intestines 18 

Latin,  Medical  (see  Miscella- 
neous and  Pharmacy) 14, 16 

Life  Insurance.. 14 

Lungs II 

Massage 12 

Materia  Medica 12 

Mechanotherapy  12 


SUBJECT.  PAGE 

Medical  Jurisprudence 13 

Mental  Therapeutics 4 

Microscopy 13 

Milk  Analysis  (see  Chemistry)      4 

Miscellaneous  14 

Nervous  Diseases  14 

Nose , 20 

Nursing 15 

Obstetrics 16 

Ophthalmology 9 

Organotherapy 14 

Osteology  (see  Anatomy) 3 

Pathology 16 

Pharmacy 16 

Physical  Diagnosis 6 

Physical  Training 12 

Physiology  17 

Pneumotherapy 14 

Poisons  (see  Toxicology) .......  13 

Practice  of  Medicine 18 

Prescription  Books  (Pharm'y),  16 

Refraction  (see  Eye) 9 

Rest 14 

Sanitary  Science 11 

Skin 19 

Spectacles  (see  Eye) 9 

Spine  (see  Nervous  Diseases)  14 

Stomach.  , 18 

Students'  Compends... 22,  23 

Surgery    and     Surgical     Dis- 
eases   19 

Technological  Books 4 

Temperature  Charts 6 

Therapeutics 12 

Throat  20 

Toxicology 13 

Tumors  (see  Surgery) 19 

U.  S.  Pharmacopoeia 17 

Urinary  Organs 20 

Urine 20 

Venereal  Diseases 21 

Veterinary  Medicine 21 

Visiting  Lists,  Physicians'. 
(Send  for  Special  Circular.') 

Water  Analysis ii 

Women,  Diseases  of. 21 


Self-Examination  for  Medical  Students.  3500  Questions  on 
Medical  Subjects,  with  References  to  Standard  Works  in  which  the 
correct  replies  will  be  found.  Together  with  Questions  from  State 
Examining  Boards.     3d  Edition.     Paper  Cover,  10  cts. 


SUBJECT  CATALOGUE  OF  MEDICAL  BOOKS  3 

SPSCIAI,  NOTM.— The  prices  given  in  this  catalogue  are 
net,  no  discount  can  be  allowed  retail  purchasers  under  any  considera- 
tion. This  rule  has  been  established  in  order  that  everyone  will  be 
treated  alike,  a  general  reduction  in  former  prices  having  been  made  to 
meet  previous  retail  discounts.  Upon  receipt  of  the  advertised  price  any 
book  will  be  forwarded  by  mail  or  express,  all  charges  prepaid. 


ANATOMY. 

MORRIS.  Text-Book  ot  Anatomy.  2d  Edition.  Revised  and 
Enlarged.  790  Illustrations,  214  of  which  are  printed  in  colors. 
TJumtb  Index  in  Each  Copy.  Cloth,  $6. 00 ;  Leather,  I7.00 

*'  The  ever-growing  popularity  of  the  book  with  teachers  and  students 

is  an  index  of  its  value." — Medical  Record,  New  York. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.    284  Illustrations.  ^^4  50 

CAMPBELL.  Dissection  Outlines.  Based  on  Morris' Anatomy. 
2d  Edition.  .50 

DEAVER.     Surgical  Anatomy.     A   Treatise  on  Anatomy   in  its 
Application  to  Medicine  and  Surgery.    With  400  very  Handsome  full- 
page  Illustrations  Engraved  from  Original  Drawings  made  by  special 
Artists  from  dissections  prepared  for  the  purpose.     Three  Volumes. 
Cloth,  $21.00;  Half  Morocco  or  Sheep,  $24.00 ;   Half  Russia,  $27.00 

GORDINIER.  Anatomy  of  the  Central  Nervous  System. 
With  271  Illustrations,  many  of  which  are  original.  Cloth,  $6,00 

HEATH.    Practical  Anatomy.    8th  Edition.    300  Illus.  $4,25 

HOLDEN.  Anatomy.  A  Manual  of  Dissections.  Revised  by  A. 
Hkwson,  M.D.,  Demonstrator  of  Anatomy,  Jefferson  Medical  College, 
Philadelphia.  320  handsome  Illustrations.  7th  Edition.  In  two 
compact  i2mo  Volumes.  850  Pages.  Large  New  Type.  Just  Ready. 
Vol.  I.  Scalp— Face— Orbit— Neck— Throat— Thorax— Upper  Ex- 
tremity. $1.50 
Vol.  II.  Abdomen — Perineum — Lower  Extremity — Brain — Eye — 
Ear — Mammary  Gland — Scrotum — Testes.  $1.50 

HOLDEN.  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the  Muscles. 
The  General  and  Microscopical  Structure  of  Bone  and  its  Develop- 
ment.   With  Lithographic  Plates  and  numerous  lUus.    8th  Ed.     $5.25 

HOLDEN.     Landmarks.    Medical  and  Surgical.     4th  Ed.  .75 

HUGHES  AND  KEITH.  Dissections.  With  Colored  and  other 
Illustrations.     In  three  farts:  I,  Upper  and  Lower  Extremity. 

Just  Ready.     $3.00 

II,  Abdomen— Thorax.  Just  Ready.     $3.00 

III,  Head — Neck — Central  Nervpus  System.  In  Press. 

MACALISTER.  Human  Anatomy.  Systematic  and  Topograph- 
ical.    816  Illustrations.  Cloth,  $5.00 ;  Leather,  $6.00 

McMURRICH.     Embryology.     Illustrated.  In  Press. 

MARSHALL.  Physiological  Diagrams.  Life  Size.  Colored. 
Eleven  Life-Size  Diagrams  (each  seven  feet  by  three  feet  seven 
inches).     Designed  for  Demonstration  before  the  Class. 

In  Sheets,  Unmounted,  $40.00 ;  Backed  with  Muslin  and  Mounted 
on  Rollers,  $60.00 ;  Ditto,  Spring  Rollers,  in  Handsome  Walnut  Wall 
Map  Case,  $100.00;  Single  Plates— Sheets,  $5.00 ;  Mounted,  $7.50. 
Explanatory  Key,  .50.     Purchaser  must  pay  freight  charges. 

POTTER.  Compend  of  Anatomy,  Including  Visceral  Anatomy. 
6th  Ed.    16  Lith.  Plates  and  117  other  Illus.     .80  ;  Interleaved,  $1.00 

WILSON.    Anatomy,    nth  Edition.    429  Illus.,  26  Plates.      $5.00 


SUBJECT  CATALOGUE. 


BRAIN  AND  INSANITY  (see  also 
Nervous  Diseases). 

BLACKBURN.  A  Manual  of  Autopsies.  Designed  for  the  Use 
of  Hospitals  for  the  Insane  and  other  Public  Institutions.  Ten  full- 
page  Plates  and  other  Illustrations.  ^1.25 

CHASE.     General  Paresis.     Illustrated.  In  Press. 

DERCUM.     Mental  Therapeutics,  Rest,  etc.        Nearly  Ready, 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central 
Nervous  System.     With  full-page  and  other  Illustrations.      $6.00 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous  Illustrations.  I2.50 

IRELAND.    The  Mental  Affections  of  Children.    2d  Ed.    $4.00 

LEWIS  (BEVAN).  Mental  Diseases.  A  Text-Book  Having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.  26  Litho- 
graphic Plates  and  other  Illustrations.     2d  Ed.  $700 

MANN.     Manual  of  Psychological  Medicine.  $3.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Disease. 
Illustrated.  |$t-25 

REGIS.  Mental  Medicine.  Authorized  Translation  by  H.  M. 
Bannister,  m.d.  ^2.00 

SHUTTLEWORTH.     Mentally  Deficient  Children.  ^1.50 

STEARNS.  Mental  Diseases.  With  a  Digest  of  Laws  Relating 
to  Care  of  Insane.    Illustrated.  Cloth,  ^2.75  ;  Sheep,  I3.25 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the 
Definition,  Etymology,  and  Symptoms  of  the  Terms  used  in  Medical 
Psychology,  with  the  Symptoms,  Pathology,  and  Treatment  of  the 
Recognized  Forms  of  Mental  Disorders.     Two  volumes.  ^10.00 

WOOD,  H.  C.    Brain  and  Overwork.  .40 

CHEMISTRY  AND  TECHNOLOGY. 

special   Catalogue  of  Chemical  Books  sent  free  upon  application. 

ALLEN.     Commercial   Organic   Analysis.    A  Treatise  on  the 

Modes  of  Assaying  the  Various  Organic  Chemicals  and  Products 

Employed  in  the  Arts,  Manufactures,  Medicine,  etc.,  with  concise 

methods  for  the  Detection  of  Impurities,  Adulterations,  etc.     8vo. 

Vol.  I.  Alcohols,  Neutral  Alcoholic  Derivatives,  etc..  Ethers,  Veg- 
etable Acids,  Starch,  Sugars,  etc.     3d  Edition.  ^4.50 

Vol.  II,  Part  I.  Fixed  Oils  and  Fats,  Glycerol,  Explosives,  etc. 
3d  Edition.  ^3  50 

Vol.  II,  Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants,  Benzenes, 
Naphthalenes  and  Derivatives,  Creosote,  Phenols,  etc.  3d  Ed.  ^3.50 

Vol.  II,  Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors,  etc. 
3d  Edition.  Preparing. 

Vol.  Ill,  Part  I.  Tannins,  Dyes  and  Coloring  Matters.  3d  Edition. 
Enlarged  and  Rewritten.     Illustrated.  ^4.50 

Vol.  Ill,  Part  II.  The  Amines,  Hydrazines  and  Derivatives, 
Pyridine  Bases.  The  Antipyretics,  etc.  Vegetable  Alkaloids,  Tea, 
Coffee,  Cocoa,  etc.     8vo.     2d  Edition.  $4-5o 

Vol.  Ill,  Part  III.  Vegetable  Alkaloids,  Non-Basic  Vegetable  Bitter 
Principles.  Animal  Bases,  Animal  Acids,  Cyanogen  Compounds, 
etc.    2d  Edition,  8vo.  ^4.50 

Vol.  IV.  The  Proteids  and  Albuminous  Principles.  2d  Ed.  II4.50 
BAILEY  AND  CADY.    Chemical  Analysis.    Just  Ready.  I1.25 


MEDICAL  BOOKS. 


BARTLEY.     Medical    and    Pharmaceutical    Chemistry.      A 

Text-Book  for  Medical,  Dental,  and  Pharmaceutical  Students.    With 
Illustrations,  Glossary,  and  Complete  Index.     5th  Edition.         Is-oo 

BARTLEY.  Clinical  Chemistry.  The  Examination  of  Feces, 
Saliva,  Gastric  Juice,  Milk,  and  Urine.  ^i.oo 

BLOXAM.  Chemistry,  Inorganic  and  Organic  With  Experi- 
ments.    9th  Ed..  Revised      «8i  Engravings  Preparing. 

BUNGE.  Physiologic  and  Pathologic  Chemistry.  New  En- 
larged Edition.  In  Press. 

CALDWELL.  Elements  of  Qualitative  and  Quantitative 
Chemical  Analysis.     3d  Edition,  Revised.  $1.00 

CAMERON.     Oils  and  Varnishes,     With  Illustrations.  ^2.25 

CAMERON.     Soap  and  Candles.     54  Illustrations.  ^2,00 

CLOWES  AND  COLEMAN.  Quantitative  Analysis.  5th 
Edition.     122  Illustrations.  $3>5o 

COBLENTZ.  Volumetric  Analysis.  Illustrated.  yi<.rz'/?<ra^^.  $1.25 

CONGDON.  Laboratory  Instructions  in  Chemistry.  With 
Numerous  Tables  and  56  Illustrations.  ^i.oo 

GARDNER.  The  Brewer,  Distiller,  and  Wine  Manufac- 
turer.    Illustrated.  >i.5o 

GRAY.  Physics.  Volume  I.  Dynamics  and  Properties  of  Matter. 
350  Illustrations.  j4-50 

GROVES  AND  THORP.    Chemical  Technology.    The  Appli- 
cation  of   Chemistry   to  the   Arts  and   Manufactures. 
Vol.  I.  Fuel  and  Its  Applications.     607  Illustrations  and  4  Plates. 

Cloth,  I5.00;   ^Mor.,$6.5o 
Vol.11.    Lighting.      Illustrated.  Cloth,  I4.00;   >^  Mor.,  I5. 50 

Vol.  III.  Gas  Lighting.  Cloth,  ^3.50  ;   J4  Mor.,  $4.50 

Vol.  IV.  Electric  Lighting.     Photometry.  In  Press. 

HEUSLER.     The  Terpenes.  In  Press. 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.     6th  Ed.     Illustrated  and  interleaved,  |i.oo 

LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic 
and  Organic.     4th  Edition,  Revised.  .80  ;  Interleaved,  Ji. 00 

LEFFMANN.      Analysis   of   Milk   and   Milk    Products.      2d 
Edition,  Enlarged.     Illustrated.  $1-25 

LEFFMANN.  W^ater  Analysis.  For  Sanitary  and  Technic  Pur- 
poses.    Illustrated.     4th  Edition.  |i.25 

LEFFMANN.  Structural  Formulae.  Including  180  Structural 
and  Stereo-Chemical  Formulae.     i2mo.     Interleaved.  Ji.oo 

LEFFMANN  AND  BEAM.  Select  Methods  in  Food  Analy- 
sis.    Illustrated.  J2  50 

MUTER.  Practical  and  Analytical  Chemistry.  2d  American 
from  the  Eighth  English  Edition.  Revised  to  meet  the  requirements 
of  American  Students.     56  Illustrations.  |i-25 

OETTEL.     Exercises  in  Electro-Chemistry.     Illustrated.        .75 

OETTEL.     Electro-Chemical  Experiments.     Illustrated.         .75 

RICHTER.  Inorganic  Chemistry.  5th  American  from  loth  Ger- 
man Edition.  Authorized  translation  by  Edgar  F.  Smith,  m.a., 
PH.D.     89  Illustrations  and  a  Colored  Plate.  ^i-75 

RICHTER.  Organic  Chemistry.  3d  American  Edition.  Trans, 
from  the  8th  German  by  Edgar  F.  Smith.  Illustrated.  2  Volumes. 
Vol.    I.    Aliphatic  Series.     625  Pages.  J>3.oo 

Vol.  II.    Carbocyclic  Series.     671  Pages.  ^3.00 


SUBJECT  CATALOGUE. 


ROCKWOOD.     Chemical  Analysis  for  Students  of  Medicine, 

Dentistry,  and  Pharmacy.     Illustrated.    Just  Ready.  $i-5o 

SMITH.     Electro-Chemical  Analysis.    2d  Ed.    28  Illus.       1^1.25 

SMITH  AND  KELLER.     Experiments.     Arranged  for  Students 

in  General  Chemistry.     4th  Edition.     Illustrated  .60 

SUTTON.    Volumetric  Analysis.     A  Systematic  Handbook  for 

the  Quantitative  Estimation  of  Chemical  Substances  by  Measure, 

Applied  to  Liquids,  Solids,  and  Gases.      8th  Edition,  Revised.     112 

Illustrations.  J5.00 

SYMONDS.     Manual  of  Chemistry.    2d  Edition.  ^2.00 

TRAUBE.     Physico-chemical  Methods.    Translated  by  Hardin. 

97  Illustrations.  ^1.50 

THRESH.     Water  and  Water  Supplies.    3d  Edition.  $2.00 

ULZER  AND   FRAENKEL.     Chemical  Technical  Analysis. 

Translated  by  Fleck.     Illustrated.  $1-25 

WOODY.     Essentials    of    Chemistry    and     Urinalysis.      4th 

Edition.     Illustrated.  Ji-So 

*#*  Special  Catalogue  0/  Books  on  Chemistrv  free  upon  application. 


CHILDREN. 

CAUTLEY.    Feeding  of  Infants  and  Young  Children  by  Nat- 
ural and  Artificial  Methods.  $2.00 
HALE.     On  the  Management  of  Children.  .50 

HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     2d  Edition.  .80;    Interleaved,  $1.00 

IRELAND.  The  Mental  Affections  of  Children.  Idiocy, 
Imbecility,  Insanity,  etc.     2d  Edition.  J4.00 

POW^ER.  Surgical  Diseases  of  Children  and  their  Treat- 
ment by  Modern  Methods.     Illustrated.  ^2.50 

SHUTTLEWORTH.  Mentally  Deficient  Children.  New 
Edition.  ^i-5o 

STARR.  The  Digestive  Organs  in  Childhood.  The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.  3d  Edition,  Rewrit- 
ten and  Enlarged.     Illustrated.     Just  Ready.  $3co 

STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic  Manage- 
ment of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.  $1.00 

SMITH.     "Wasting  Diseases  of  Children.    6th  Edition.        ^2.00 

TAYLOR  AND  WELLS.  The  Diseases  of  Children.  2d  Edi- 
tion, Revised  and  Enlarged.     Illustrated.     Bvo.  $4-5o 

DIAGNOSIS. 

BROWN.  Medical  Diagnosis.  A  Manual  of  Clinical  Methods. 
4th  Edition.     112  Illustrations.  Cloth,  ^2.25 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  Exam- 
ination of  Blood.  6  Colored  Plates.  48  other  Illustrations.  Just 
Ready.  Cloth,  $5.00  ;  Sheep,  $6  00 

EMERY.     Bacteriological  Diagnosis.    Just  Ready.  $i-5o 

MEMMINGER.   Diagnosis  by  the  Urine.   2d  Ed.   24  Illus.  ^i.oo 


MEDICAL   BOOKS. 


PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases. 
Illustrated.  $125 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  $1.25 

TYSON.  Hand-Book  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Medicine  in  the  University 
of  Pennsylvania.  Illus.  4th  Ed.,  Improved  and  Enlarged.  With 
Two  Colored  and  55  other  Illustrations.  $r-50 


DENTISTRY. 

special  Catalogue  0/  Dental  Books  sent  free  upon  application. 

BARRETT.  Dental  Surgery  for  General  Practitioners  and 
Students  of  Medicine  and  Dentistry.  Extraction  of  Teeth, 
etc.     3d  Edition.     Illustrated.  $1.00 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.     284  Handsome  Illustrations.  ^4.50 

FILLEBROWN.      A    Text-Book    of    Operative     Dentistry. 

Written  by  invitation  of  the  National  Association  of  Dental  Facul- 
ties.    Illustrated.  ^2.25 

QORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.    7th  Edition.    Just  Ready.   Cloth,  J4.00;  Sheep,  $5.00 

GORGAS.  Questions  and  Answers  for  the  Dental  Student. 
Embracing  all  the  subjects  in  the  Curriculum  of  the  Dental  Student. 
Octavo.     Just  Ready.  ^6.00 

HARRIS.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery, 
and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S.  Gorgas,  m.d., 
D.D.S.     1250  Illustrations.  Cloth,  $6.00;  Leather,  ^7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.  6th  Edition.  Revised  and  Enlarged  by  Fer- 
dinand F.  S.  Gorgas,  m.d.,  d.d.s.         Cloth,  ;g5.oo  ;  Leather,  ^6.00 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Edition.  187 
Illustrations.  ^4.50 

RICHARDSON.     Mechanical   Dentistry.     7th   Edition.     Thor- 
oughly Revised  and  Enlarged  by  Dr.  Geo.  W.  Warren.     691  Illus- 
trations. Cloth,  $5.00;  Leather,  $6.00 
SMITH.     Dental  Metallurgy.     Illustrated.  $1.75 
TAFT,     Index  of  Dental  Periodical  Literature.  $2.00 

TOMES.     Dental  Anatomy.    Human  and  Comparative.    263  Illus- 
trations.    5th  Edition.  I4.0C 
TOMES.     Dental  Surgery.     4th  Edition.     289  Illustrations.     $4.00 

WARREN.  Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    With  a  Chapter  on  Emergencies.     3d  Edition.     Illustrated. 

.80;  Interleaved,  $1.25 
WARREN.  Dental  Prosthesis  and  Metallurgy.  129  Ills.  ^1.25 
WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 


SUBJECT  CATALOGUE. 


DICTIONARIES  AND  CYCLOPEDIAS 

GOULrD.  The  Illustrated  Dictionary  ot  Medicine,  Biology 
and  Allied  Sciences.  Being  an  Exhaustive  Lexicon  of  Medicine 
and  those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistry,  Parmacology,  Microscopy,  eic,  with  many 
useful  Tables  and  numerous  fine  Illustrations.  1633  pages.  5th  Ed. 
Sheep  or  Half  Dark  Green  Leather,  $10,00;  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12.00 

GOULD.  The  Medical  Student's  Dictionary,  nth  Edition. 
Illustrated.  Including  all  the  Words  and  Phrases  Generally  Used 
inMedicine,  with  their  Proper  Pronunciation  and  Definition,  Based 
•  on  Recent  Medical  Literature.  With  Table  of  Eponymic  Terms  and 
Tests  and  Tables  of  the  Bacilli,  Micrococci,  Mineral  Springs,  etc., 
of  the  Arteries,  Muscles,  Nerves,  Ganglia,  Plexuses,  etc.  nth  Edi- 
tion. Enlarged  and  illustrated  with  a  large  number  of  Engravings. 
840  pages.  Half  Green  Morocco,  $2.50;  Thumb  Index,  $3  00 

GOULD.  The  Pocket  Pronouncing  Medical  Lexicon.  4th  Edi- 
tion. (30,000  Medical  Words  Pronounced  and  Defined.)  Containing 
all  the  Words,  their  Definition  and  Pronunciation,  that  the  Medical, 
Dental,  or  Pharmaceutical  Student  Generally  Comes  in  Contact 
With ;  also  Elaborate  Tables  of  Eponymic  Terms.  Arteries,  Muscles, 
Nerves,  Bacilli,  etc.,  etc.,  a  Dose  List  in  both  English  and  Metric 
Systems,  etc..  Arranged  in  a  Most  Convenient  Form  for  Reference  and 
Memorizing.  Fourth  Edition,  Revised  and  Enlarged.  '838 
pages.  Full  Limp  Leather,  Gilt  Edges,  $1,00  ;  Thumb  Index,  I1.25 
130,000  Copies  of  Gould's  Dictionaries  Have  Been  Sold. 

GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  Seventy-two  Special  Contributors.  Illustrated. 
One  Volume.  A  Concise  Reference  Handbook,  Alphabetically 
Arranged,  of  Medicine,  Surgery,  Obstetrics,  Materia  Medica, 
Therapeutics,  and  the  Various  Specialties,  with  Particular  Reference 
to  Diagnosis  and  Treatment.  Compiled  under  the  Editorial  Super- 
vision of  George  M.  Gould,  m.d..  Author  of  "An  Illustrated 
Dictionary  of  Medicine  "  :  Editor  "  Philadelphia  Medical  Journal," 
etc.;  and  Walter  L.  Pyle,  m.d..  Assistant  Surgeon  Wills  Eye 
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HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  ot  Sucn 
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Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s.   Cloth,  $5.00;  Leather,  $6.00 

LONGLEY.  Pocket  Medical  Dictionary.  With  an  Appendix, 
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scriptions, etc.  Cloth,  .75  ;  Tucks  and  Pocket,  $1.00 

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EAR  (see  also  Throat  and  Nose). 

BURNETT.     Hearing  and  How  to  Keep  It.    Illustrated.  .40 

DALBY.      Diseases  and  Injuries  of  the  Ear.    4th  Edition.     38 

Wood  Engravings  and  8  Colored  Plates.  J2.50 

HOVELL.  Diseases  ot  the  Ear  and  Naso-Pharynx.  Includ- 
ing Anatomy  and  Physiology  of  the  Organ,  together  with  the  Treat- 
ment of  the  Affections  of  the  Nose  and  Pharynx  which  Conduce  to 
Aural  Disease.     128  Illustrations.     2d  Edition.    Just  Ready.      J5.50 

PRITCHARD.  Diseases  of  the  Ear.  3d  Edition,  Enlarged. 
Many  Illustrations  and  Formulae.  $1.50 

ELECTRICITY. 

BIGELOW.  Plain  Talks  on  Medical  Electricity  and  Bat- 
teries. With  a  Therapeutic  Index  and  a  Glossary.  43  Illustra- 
tions.    2d  Edition.  $1.00 

HEDLEY.  Therapeutic  Electricity  and  Practical  Muscle 
Testing.    99  Illustrations.  *  J2.50 

JACOBY.   Electrotherapy.  2  Vols.   Illustrated.   Including  Special 

Articles  by  Various  Authors.     {Subscription.)  $5.00 

JONES.   Medical  Electricity.  3d  Edition.   117  lUus.  J3.00 


EYE. 

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DONDERS.  The  Nature  and  Consequences  of  Anomalies  of 
Refraction.     With  Portrait  and  Illustrations.     Half  Morocco,  $1.25 

PICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Trans- 
lated by  A.  B.  Hale,  m.  d.  157  Illustrations,  many  of  which  are  in 
colors,  and  a  glossary.  Cloth,  J4.50;  Sheep,  J5.50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and 
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on  Local  Therapeutics.  With  Formulae,  Useful  Tables,  a  Glossary, 
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GREEFF.  The  Microscopic  Examination  of  the  Eye.  Illus- 
trated.   Just  Ready.  $125 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illus.  .40 

HARTRIDGE.  Refraction.  104  Illustrations  and  Test  Types, 
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4  Colored  Plates  and  68  Wood-cuts.  J1.50 

HANSELL  AND  REBER.     Muscular  Anomalies  of  the  Eye. 

Illustrated.  J1.50 

HANSELL  AND  BELL.  Clinical  Ophthalmology.  Colored 
Plate  of  Normal  Fundus  and  120  Illustrations.  I1.50 

JENNINGS.  Manual  of  Ophthalmoscopy.  95  Illustrations  and 
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10  SUBJECT  CATALOGUE. 

MORTON.     Refraction  of  the  Eye.    Its  Diagnosis  and  the  Cor- 
rection of  its  Errors.     6th  Edition.  $1.00 

OHLEMANN.     Ocular  Therapeutics.    Authorized  Translation, 
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matic Illustrations.    Just  Ready.  %i.oo 

PHILLIPS.     Spectacles  and  Eyeglasses.      Their  Prescription 
and  Adjustment    2d  Edition.     49  Illustrations.  |i.oo 

SWANZY.     Diseases  of  the  Eye  and  Their  Treatment.     7th 

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and  a  Zephyr  Test  Card.  ^  I2.50 

From  The  Medical  Netvs, 

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THORINGTON.    Retinoscopy.     4th  Edition.     Carefully  Revised. 
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GUSHING.  Compend  of  Histology.  By  H.  H.  Gushing,  m.d.. 
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STIRLING.  Outlines  of  Practical  Histology.  368  Illustrations. 
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STOHR.  Histology  and  Microscopical  Anatomy.  Edited  by 
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HYGIENE  AND  WATER  ANALYSIS. 

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CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
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CONN.     Agricultural  Bacteriology.     Illus.   Just  Ready.      ^2.50 

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LINCOLN.    School  and  Industrial  Hygiene.  .40 

McFARLAND.  Prophylaxis  and  Personal  Hygiene.  Care  of 
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NOTTER.  The  Theory  and  Practice  of  Hygiene.  15  Plates 
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PARKES.  Hygiene  and  Public  Health.  By  Louis  C.  Parkes, 
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PARKES.  Popular  Hygiene.  The  Elements  of  Health.  A  Book 
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STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
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Management  of  the  Ordinary  Emergencies  of  Early  Life,  Massage, 
etc.     6th  Edition.     25  Illustrations.  ^i.oo 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
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THRESH.     Water  and  Water  Supplies.    3d  Edition.  $2.00 

WILSON.  Hand-Book  of  Hygiene  and  Sanitary  Science. 
With  Illustrations.     8th  Edition.  ^3.00 

WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  Author- 
ized Translation  by  Henry  Leffmann,  m.d.,  ph.d.  $1.25 


LUNGS  AND  PLEURiE. 

KNOPF.      Pulmonary  Tuberculosis.     Its   Modern  Prophylaxis 
and  Treatment  in  Special  Institutions  and  at  Home.     Illus.        J?3.oo 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  Illus.  $1.25 


SUBJECT  CATALOGUE. 


MASSAGE— PHYSICAL  EXERCISE. 

OSTROM.  Massage  and  the  Original  Swedish  Move- 
ments. Their  Application  to  Various  Diseases  of  the  Body.  A 
Manual  for  Students,  Nurses,  and  Physicians.  Fourth  Edition,  En- 
larged.    105  Illustrations,  many  of  which  are  original.  |i.oo 

MITCHELL  AND  GULICK.  Mechanotherapy.  lUus.  InPress. 

TREVES.     Physical  Education.    Methods,  etc.  .75 

WARD.     Notes  on  Massage.     Interleaved.         Paper  cover,  Ji. 00 


MATERIA    MEDICA    AND     THERA- 
PEUTICS. 

BIDDLE.  Materia  Medica  and  Therapeutics.  Including  Dose 
List,  Dietary  for  the  Sick,  Table  of  Parasites,  and  Memoranda  ot 
New  Remedies.  13th  Edition,  Revised.  64  Illustrations  and  a 
Clinical  Index.  Cloth,  ^4.00;  Sheep,  ^5.00 

BRACKEN.     Outlines  of  Materia  Medica  and  Pharmacology.    I2.75 

COBLENTZ.  The  Newer  Remedies.  Including  their  Synonyms, 
Sources,  Methods  of  Preparation,  Tests,  Solubilities,  Doses,  etc. 
3d  Edition,  Enlarged  and  Revised.  ^i.oo 

COHEN.  Physiologic  Therapeutics.  Mechanotherapy,  Mental 
Therapeutics,  Electrotherapy.  Climatology,  Hydrotherapy,  Pneu- 
matotherapy.  Prophylaxis,  Dietetics,  etc.  11  Volumes,  Octavo. 
Illustrated.     ^Subscription.)  Cloth,  ^27.50  ;  J^  mor.,  $38.50 

Special  Descriptive  Circular  will  be  sent  upon  application. 
DAVIS.     Materia  Medica  and  Prescription  'Writing.        $1.50 

GORQAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition,  Revised,     fust  Ready.  $4-oo 

GROFF.  Materia  Medica  for  Nurses,  with  questions  for  Self- Exam- 
ination and  a  complete  Glossary.  $1-25 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and 
Prescription  Writing.  ?i.50 

MAYS.    Theine  in  the  Treatment  of  Neuralgia.    J^  bound,  .50 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics,  including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and  For- 
mulae. 8th  Edition,  Revised  and  Enlarged.  With  Thumb  Index  in 
each  copy.  Cloth,  I5.00;  Sheep,  f6.oo 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  Writing,  with  Special  Reference  to  the  Physiologi- 
cal Action  of  Drugs.     6th  Edition.  .80;  Interleaved,  $1.00 

MURRAY.     Rough  Notes  on  Remedies.    4th  Edition.         $1.25 


MEDICAL  BOOKS. 


SAYRE.    Organic  Materia  Medica  and  Pharmacognosy.    An 

Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepara- 
tions,  Insects  Injurious  to  Drugs,  and  Pharmacal  Botany.  With 
sections  on  Histology  and  Microtechnique,  by  W.  C.  Stevens. 
374  Illustrations,  many  of  which  are  original.    2d  Edition. 

Cloth,  I4.50 

TAVERA.     Medicinal  Plants  of  the  Philippines,    fust  Ready. 

$2.00 

WHITE  AND  WILCOX.    Materia  Medica,  Pharmacy,  Phar- 

macology,  and  Therapeutics.  5th  American  Edition,  Revised  by 
Reynold  W.  Wilcox,  m.a.,  m.d.,  ll.d..  Professor  of  Clinical 
Medicine  and  Therapeutics  at  the  New  York  Post-Graduate  Medica4 
School.  Cloth,  $3.00;  Leather,  $3.50 

"  The  care  with  which  Dr.  Wilcox  has  performed  his  work  is  con- 
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ing any  merit  has  escaped  his  eye.  We  believe,  on  the  whole,  this  is 
the  best  book  on  Materia  Medica  and  Therapeutics  to  place  in  the 
hands  of  students,  and  the  practitioner  will  find  it  a  most  satisfactory 
work  for  daily  use." — The  Cleveland  Medical  Gazette. 


MEDICAL    JURISPRUDENCE     AND 
TOXICOLOGY. 


REESE.   Medical  Jurisprudence  and  Toxicology.  A  Text-Book 

for  Medical  and  Legal   Practitioners  and  Students.     5th   Edition. 
Revised  by  Henry  Leffmann,  m.d.       Clo.,^3.00;  Leather,  I3.50 


"  To  the  student  of  medical  jurisprudence  and  toxicology  it  is  in- 
valuable, as  it  is  concise,  clear,  and  thorough  in  every  respect." — The 
American  Journal  of  the  Medical  Sciences. 

MANN.     Forensic  Medicine  and  Toxicology.     lUus.  ^6.50 

TANNER.     Memoranda  of  Poisons.    Their  Antidotes  and  Tests. 
8th  Edition,  by  Dr.  Henry  Leffmann.  .75 


MICROSCOPY. 

CARPENTER.     The  Microscope  and    Its   Revelations.    8th 

Edition,  Revised  and  Enlarged.      817  Illustrations  and  23    Plates. 
Just  Ready.  Cloth,  |8.oo  ;  Half  Morocco,  ^.00 

LEE.  The  Microtomist's  Vade  Mecum.  A  Hand-Book  of 
Methods  of  Microscopical  Anatomy.  887  Articles.  5th  Edition, 
Enlarged.  ^4-oo 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology.  Neoplasms,  Urinary  Examination,  etc.  Numerous  Illus- 
trations, some  of  which  are  printed  in  colors.  ^2.50 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the 
Microscope  in  Practical  Medicine.    100  lUustratioos.  ^2.00 


SUBJECT  CATALOGUE. 


MISCELLANEOUS. 

BERRY.     Diseases  of  Thyroid  Gland.     Illustrated.  I4.00 

BURNETT.     Foods  and  Dietaries.    A  Manual  of  Clinical  Diet- 
etics.    2d  Edition.  |i-5o 
BUXTON.     Anesthetics.     Illustrated.     3d  Edition.                   $1.50 
COHEN.     Organotherapy.                                                       In  Press. 
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Tables  of  Dietaries,  Relative  Value  of  Foods,  etc.     {Subscription.) 
Just  Ready.                                                                                              $2.50 
GOULD.      Borderland    Studies.      Miscellaneous  Addresses  and 
Essays.     i2mo.                                                                                         $2.00 
GREENE.     Medical  Examination  for  Life  Insurance.     Illus- 
trated.    With  Colored  and  other  Engravings.                                     $4.00 
HAIG.    Causation  of  Disease  by  Uric  Acid.    The  Pathology  of 
High  Arterial  Tension,  Headache,  Epilepsy,  Gout,    Rheumatism, 
Diabetes,  Bright's  Disease,  etc.     sthEdition.                                  $3.00 
HAIG.     Diet  and  Food.    Considered  in  Relation  to  Strength  and 
Power  of  Endurance.     3d  Edition.                                                     |i.oo 
HENRY.    A  Practical  Treatise  on  Anemia.          Hali  Cloth,  .50 
LEFFMANN.     Food  Analysis.     Illustrated.                             ^2.50 
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NERVOUS  DISEASES. 

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GOWERS.  Manual  of  Diseases  of  the  Nervous  System,  A 
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written. With  many  new  Illustrations.  Two  volumes. 
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larged. Cloth,  $4,00;  Sheep,  $5.00 
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GOWERS.    Syphilis  and  the  Nervous  System.  $1.00 


MEDICAL  BOOKS.  16 


GOWERS.   Epilepsy  and  Other  Chronic  Convulsive  Diseases. 

2d  Edition,     fust  Ready.  Js.cx) 

HORSLEY.    The   Brain   and  Spinal  Cord.    The  Structure  and 

Functions  of.     Numerous  Illustrations.  $2  50 

ORMEROD.     Diseases  of  the  Nervous  System.    66  Wood  En. 
gravings.  $1.00 

PERSHING.      Diagnosis  of  Nervous  and  Mental  Diseases. 

Illustrated.  ^*-25 

PRESTON.    Hysteria  and  Certain  Allied  Conditions.    Their 

Nature  and  Treatment.     Illustrated.  ^.00 

WOOD.     Brain  'Work  and  Overwork.  .40 


NURSING  (see  also  Massage). 

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CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses  and 
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tion, Bacteriology,  Immunity,  Heating  and  Ventilation,  and  Kindred 
Subjects  for  the  Use  of  Nurses  and  Other  Intelligent  Women.     I1.25 

CUFF.    Lectures  to  Nurses  on  Medicine.    Third  Edition.    ^1.25 

DOMVILLE.     Manual  for  Nurses  and  Others  Engaged  in  At- 
tending the  Sick.   9th  Edition.  With  Recipes  for  Sick-room  Cook- 
ery, etc.  In  Press, 
FULLERTON.    Obstetric  Nursing.    41  Ills.    5th  Ed.  ^i.oo 
FULLERTON.     Surgical    Nursing.    3d  Ed.    69  Ills.          Ji.oo 

GROFF.     Materia  Medica  for  Nurses.     With  Questions  for  Self-Ex- 

amination  and  a  very  complete  Glossary.  $i-25 

"  It  will  undoubtedly  prove  a  valuable  aid  to  the  nurse  in  securing  a 

knowledge  of  drugs  and  their  uses.*' — The  Medical  Record,  New 

York. 

HADLEY.     General,  Medical,  and  Surgical  Nursing.     Avery 

Complete  Manual,  Including  Sick-Room  Cookery,  fust  Ready.  $1.25 

HUMPHREY.      A    Manual    for     Nurses.      Including    General 

Anatomy  and    Physiology,  Management  of  the   Sick   Room,    etc 

23d  Edition.     79  Illustrations.  $1.00 

"  In  the  fullest  sense.  Dr.  Humphrey's  book  is  a  distinct  advance  on 

all   previous   manuals.     It   is,  in   point   of  fact,  a  concise  treatise  on 

medicine  and  surgery  for  the  beginner,  incorporating  with  the  text  the 

management  of  childbed  and  the  hygiene  of  the  sick-room.     Its  value 

is  greatly  enhanced  by  copious  wood-cuts  and  diagrams  of  the  bones 

and  internal  organs." — British  Medical  four nal,  London. 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic  Man- 
agement of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.  ^i.oo 

TEMPERATURE  AND  CLINICAL  CHARTS.    See  page  6. 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Enlarged. 
112  Illustratioos.  |i.oo 


16  SUBJECT  CATALOGUE. 

OBSTETRICS. 

CAZEAUX  AND  TARNIER.  Midwifery.  With  Appendix  by 
Mund6.  The  Theory  and  Practice  of  Obstetrics,  including  the  Dis- 
eases ot  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc. 
8th  Edition.  Illustrated  by  Colored  and  other  full-page  Plates,  and 
numerous  Wood  Engravings.  Cloth,  $4.50  ;  Full  Leather,  $5.50 

EDGAR.     Text- Book  of  Obstetrics.     Illustrated.       Preparing. 

FULLERTON.    Obstetric  Nursing.     5th  Ed.    Illustrated.    $1.00 

LANDIS.  Compend  of  Obstetrics.  7th  Edition,  Revised  by  Wm. 
H.  Wells,  Demonstrator  ot  Clinical  Obstetrics,  JeflFerson  Medical 
College.     52  Illustrations.  .80;  Interleaved,  jpi. 00 

WINCKEL.  Text-Book  of  Obstetrics,  Including  the  Pathol- 
ogy and  Therapeutics  of  the  Puerperal  State.  Authorized 
Translation  by  J.  Clifton  Edgar,  m.d.     Illustrated.  J5.00 

PATHOLOGY. 

BARLOW.    General  Pathology.     795  pages.    8vo.  $5.00 

BLACK.     Micro-Organisms.     The  Formation  of  Poisons.  .75 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed  for 
the  Use  ot  Hospitals  for  the  Insane  and  other  Public  Institutions. 
Ten  full-page  Plates  and  other  Illustrations.  ^1-25 

CONN.    Agricultural  Bacteriology.     Illus.   Just  Ready.      $2.50 
COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Technic 
of  Post-Mortems,  Methods  of  Pathologic  Research,  etc.     330  Illus- 
trations, 7  Colored  Plates.     3d  Edition.  ^3-50 
DA  COSTA.     Clinical  Hematology.      Six  Colored  Plates  and  48 
Illustrations,    fust  Ready.                             Cloth,  $5.00;  Sheep,  $6.00 
EMERY.     Bacteriological  Diagnosis.     2  Colored  Plates  and  32 
other  Illustrations.    Just  Ready.  $1.50 
HEWLETT.     Manual  of  Bacteriology.   75  Illustrations.    Second 
Edition,  Revised  and  Enlarged.                                                   In  Press. 
ROBERTS.   Gynecological  Pathology.   IWus.  Just  Ready    $6.00 
THAYER.       Compend    of    General    Pathology.       Illustrated. 
Just  Ready.     .80  ;  Interleaved,  Ji.co 
THAYER.     Compend  of  Special  Pathology.     Illustrated. 

Nearly  Ready.     .80;  Interleaved,  ^i. 00 
VIRCHOW.     Post-Mortem  Examinations.    3d  Edition.         .75 
WHITACRE.     Laboratory  Text-Book  of   Pathology.     With 
121  Illustrations.  $i-5o 

WILLIAMS.  Bacteriology.  A  Manual  for  Students.  90  Illus- 
trations.    2d  Edition,  Revised.  $i-50 

PHARMACY. 

special  Catalogue  of  Books  on  Pharmacy  sent  free  upon  application. 

COBLENTZ.  Manual  of  Pharmacy.  A  Complete  Text-Book 
by  the  Professor  in  the  New  York  College  of  Pharmacy.  2d  Edition, 
Revised  and  Enlarged.   437  Illus.  Cloth,  I3. 50;  Sheep,  $4.50 

COBLENTZ.    Volumetric  Analysis.     Illustrated.  In  Press. 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  ot  the  Materia 
Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Established  Pre- 
parations, an  I»dexof  Diseases  and  their  Remedies.     7th  Ed.    $e.oo 


MEDICAL  BOOKS.  17 


BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprietary 
Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cosmetics, 
Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chemicals, 
Scientific  Processes,  and  many  Useful  Tables.     loth  Ed.  |2.oo 

BEASLEY.  Pharmaceutical  Formulary.  A  Synopsis  of  the 
British,  French,  German,  and  United  States  Pharmacopoeias.  Com- 
prising Standard  and  Approved  Formulae  for  the  Preparations  and 
Compounds  Employed  in  Medicine.     12th  Edition.  ^2.00 

PROCTOR.  Practical  Pharmacy.  3d  Edition,  with  Illustrations 
and  Elaborate  Tables  of  Chemical  Solubilities,  etc.  $3-oo 

ROBINSON.      Latin  Grammar  of  Pharmacy  and   Medicine. 

3d  Edition.     With  elaborate  Vocabularies.  t^-75 

SAYRE.    Organic  Materia  Medica  and  Pharmacognosy.    An 

Introduction  to  the  Study  of  the  Vegetable  Kinedom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepar- 
ations, Insects  Injurious  to  Drugs,  and  Parmacal  Botany.  With 
sections  on  Histology  and  Microtechnique,  by  W.  C.  Stevens. 
374  Illustrations.    Second  Edition.  Cloth,  ^4.50 

SCOVILLE.  The  Art  of  Compounding.  Second  Edition,  Re- 
vised and  Enlarged.  Cloth,  ^2.50 

STEWART.  Compend  of  Pharmacy.  Based  upon  "  Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  in  Accord- 
ance with  the  U.  S.  Pharmacopoeia,  1890.  Complete  Tables  of 
Metric  and  English  Weights  and  Measures.     .80;    Interleaved,  $1.00 

TAVERA.     Medicinal  Plants  of  the  Philippines,    /usi  Ready. 

^2.00 

UNITED  STATES  PHARMACOPCEIA.  7th  Decennial  Revision. 
Cloth,  $2.50  (postpaid,  $2.77) ;  Sheep,  $3.00  (postpaid,  $3.27) ;  Inter- 
leaved, «4.oo  (postpaid.  I4.50);  Printed  on  one  side  of  page  only, 
unbound,  $3.50  (postpaid,  J3.90). 

Select  Tables  from  the  U.  S.  P.    Being  Nine  of  the  Most  Impor- 
tant and  Useful  Tables,  Printed  on  Separate  Sheets.  .25 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.    600  Prescriptions.    8th  Ed.    Clo.,  I5.00;  Sh.,  ^6.00 


PHYSIOLOGY. 

BIRCH.  Practical  Physiology.  An  Elementary  Class  Book. 
62  Illustrations.  |i-75 

BRUBAKER.  Compend  of  Physiology.  loth  Edition,  Revised 
and  Enlarged.     Illustrated.  .80;  Interleaved,  ^i.oo 

JONES.    Outlines  of  Physiology.    96  Illustrations.  ^1.50 

KIRKES.  Handbook  of  Physiology.  17th  Authorized  Edition. 
Revised,  Rearranged,  and  Enlarged.  By  Prof.  W.  D.  Hallibur- 
ton, of  Kings  College,  London.  681  Illustrations,  some  of  which 
are  in  colors.  Cloth,  $3.00;  Leather,  ^3.75 


SUBJECT  CATALOGUE. 


LANDOIS.  A  Text-Book  of  Human  Physiology,  Including 
Histology  and  Microscopical  Anatomy,  with  Special  Reference  to 
the  Requirements  of  Practical  Medicine.  5th  American,  translated 
from  the  9th  German  Edition,  with  Additions  by  Wm.  Stirling, 
M.D.,D.sc.    845  lUus.,  many  of  which  are  printed  in  colors.    In  Press. 

STARLING.     Elements  of  Human  Physiology.    100  Ills.    $1.00 

STIRLING.  Outlines  of  Practical  Physiology.  Including 
Chemical  and  Experimental  Physiology,  with  Special  Reference  to 
Practical  Medicine.     3d  Edition.     289  Illustrations.  ^2.00 

TYSON.     Cell  Doctrine.    Its  History  and  Present  State.        $1.50 

PRACTICE. 

BEALE.    On  Slight  Ailments;  their  Nature  and  Treatment. 

2d  Edition,  Enlarged  and  Illustrated.  $1-25 

FAGGE.  Practice  of  Medicine.  4th  Edition,  by  P.  H.  Pye- 
Smith,  M.D.     2  Volumes.  ht  Press. 

FOWLER.  Dictionary  of  Practical  Medicine.  By  various 
writers.  An  Encyclopaedia  of  Medicine.  Clo.,  $3.00;  Half  Mor.  $4.00 
GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  A  Concise  Reference  Hanubook,  Alphabetically 
Arranged,  with  particular  Reference  to  Diagnosis  and  Treatment. 
Edited  by  Drs.  Gould  and  Pyle,  Assisted  by  72  Special  Con- 
tributors. Illustrated,  one  volume.  Large  Square  Octavo,  Uniform 
with  "  Gould's  Illu<;trated  Dictionary." 

Sheep  or  Half  Morocco,  $10.00:  with  Thumb  Index,  Jii.oo 
Half  Russia,  Thumb  Index,  $12  go 

4^  Complete  descriptive  circular  free  upon  application. 

HUGHES.  Compend  of  the  Practice  of  Medicine.  6th  Edition, 
Revised  and  Enlarged. 

Part  I.     Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the 
Stomach,   Intestines,  Peritoneum,  Biliary   Passages,  Liver,  Kid- 
neys, etc.,  and  General  Diseases,  etc. 
Part  II.     Diseases  of  the  Respiratory  System,  Circulatory  System, 
and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  .80;  Interleaved,  ;Ji.oo 

Physician's    Edition.      In  one  volume,  including  the  above  two 

parts,  a   Section  on  Skin   Diseases,  and  an  Index.     6th  Revised 

Edition.     625  pp.  Full  Morocco,  Gilt  Edge.  $2.25 

MURRAY.     Rough  Notes  on  Remedies.     4th  Ed.    Just  Ready. 

$1.25 
TAYLOR.  Practice  of  Medicine.  6th  Edition.  Just  Ready.  $i,.oo 
TYSON.  The  Practice  of  Medicine.  By  James  Tyson,  m.d., 
Professor  of  Medicine  in  the  University  of  Pennsylvania.  A  Com- 
plete Systematic  Text-book  with  Special  Reference  to  Diagnosis  and 
Treatment.  2d  Edition,  Enlarged  and  Revised.  Colored  Plates  and 
125  other  Illustrations.     1222  Pages.       Cloth,  ^5.50;  Leather,  1^6.50 

STOMACH.     INTESTINES. 

HEMMETER.  Diseases  of  the  Stomach.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy, 
Analysis  of  Stomach  Contents,  Dietetics,  Surgery  of  the  Stomach, 
etc.  2d  Edition,  Enlarged  and  Thoroughly  Revised  and  in  parts 
Rewritten.     With  Colored  and  other  Illustrations. 

Cloth,  $6.00;  Sheep,  ^7.00 


MEDICAL  BOOKS.  19 


HEMMETER.  Diseases  of  the  Intestines.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy  and 
Physiology,  Microscopic  and  Chemic  Examination  of  Intestinal 
Contents.  Secretions,  Feces  and  Urine,  Intestinal  Bacteria  and 
Parasites,  Surgery  of  the  Intestines,  Dietetics,  Diseases  of  the 
Rectum,  etc.  With  Full-page  Colored  Plates  and  many  other 
Original  Illustrations.     2  Volumes.     Octavo.     Just  Ready. 

Price  per  Volnme,  Cloth,  J5  00;   Sheep,  $6.00 


SKIN. 

BULKLEY.    The  Skin  in  Health  and  Disease.    Illustrated.    .40 
CROCKER.     Diseases  of  the  Skin.     Their  Description,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
Eruptions  of  Children.   92  Illus.   3d  Edition.  Preparing. 

SCHAMBERG.  Diseases  of  the  Skin.  2d  Edition,  Revised  and 
Enlarged.    105  Illustrations.    Being  No.  16  ?Quiz-Compend?  Series. 

Cloth,  .80;  Interleaved,  $1.00 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diagnosis  and  Treatment,  with  special  reference  to  Differential 
Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With  Formulae 
and  60  Illustrations,  some  of  which  are  printed  in  colors.        $2.75 


SURGERY  AND  SURGICAL   DIS- 
EASES (see  also  Urinary  Organs). 

BERRY.  Diseases  of  the  Thyroid  Gland  and  Their  Surgica 
Treatment.     Illustrated.    Just  Ready.  $4.00 

BUTLIN.  Operative  Surgery  of  Malignant  Disease.  2d  Edi- 
tion.    Illustrated.     Octavo.  l4-50 

DEAVER.  Surgical  Anatomy.  A  Treatise  on  Human  Anatomy 
in  its  Application  to  Medicine  and  Surgery.  With  about  400  very 
Handsome  full-page  Illustrations  Engraved  from  Original  Drawings 
made  by  special  Artists  from  Dissections  prepared  for  the  purpose. 
Three  Volumes.     Royal  Square  Octavo. 

Cloth,  $21.00;  Half  Morocco  or  Sheep,  $24.00  ;  Half  Russia,  $27.00 
Co7nplete  descriptive  circular  and  special  terins  upon  application. 

DEAVER.  Appendicitis,  Its  Symptoms,  Diagnosis,  Pathol- 
ogy, Treatment,  and  Complications.  Elaborately  Illustrated 
with  Colored  Plates  and  other  Illustrations.     2d  Edition.  l3-50 

DULLES.  What  to  Do  First  in  Accidents  and  Poisoning. 
5th  Edition.     New  Illustrations.  $1.00 

FULLERTON.     Surgical  Nursing.     3d  Edition.    69  Illus.    $1.00 
HAMILTON.     Lectures  on  Tumors.    3d  Edition.  $1.25 

HEATH.  Minor  Surgery  and  Bandaging.  12th  Edition,  Revised 
and  Enlarged.  195  Illus.,  Formulae,  Diet  List,  etc.  Just  Ready.  $1.50 
HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Ed.  $4.50 
HORWITZ.  Compend  of  Surgery  and  Bandaging,  including 
Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical  Dis- 
eases, and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential  Diagno- 
sis and  Treatment.  5th  Edition,  very  much  Enlarged  and  Rear- 
ranged.   167  Illustrations,  98  Formulae.   Clo.,  .80;  Interleaved,  $1.00 


30  SUBJECT  CATALOGUE. 

JACOBSON.    Operations    of    Surgery.    Over  200  Illustrations. 

Cloth,  $3.00 ;  Leather,  I4.00 

KEHR.  Gall-stone  Disease.  Translated  by  William  Wotkyns 
Seymour,  m.d.  I2.50 

LrANE.    Surgery  of  the  Head  and  Neck,     no  lUus.  $5-00 

MACREADY.  A  Treatise  on  Ruptures.  24  Full-page  Litho- 
graphed Plates  and  Numerous  Wood  Engravings.  Cloth,  ^6.00 

MAKINS.  Surgical  Experiences  in  South  Africa.  1899-1900. 
Illustrated.  I4.00 

MAYLARD.  Surgery  of  the  Alimentary  Canal.  97  Illustrations. 
2d  Edition,  Revised.  ^3-oo 

MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by  John  B. 
Hamilton,  m.d.,  ll.d.,  Professor  of  the  Principles  of  Surgery  and 
Clinical  Surgery,  Rush  Medical  College,  Chicago.  623  Illustrations, 
many  of  which  are  printed  in  colors.     Cloth,  J6. 00;  Leather,  ^7.00 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of 
all  the  Principal  Operations.    224  Illus.  6th  Ed.    2  Vols.  Clo.,  ^10.00 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Revised  and 
Enlarged,     in  Illustrations.  |i.oo 

WALSHAM.  Manual  of  Practical  Surgery.  7th  Ed.,  Re- 
vised and  Enlarged.   483  Engravings.   950  pages.  j3-5o 

TEMPERATURE  CHARTS,  ETC. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Temper- 
ature, Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex, 
Occupation,  Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  .50.  Price  to  Hospitals,  500 
copies,  ^4.00 ;  1000  copies,  $7.50.  With  name  of  Hospital  printed 
on,  50  cts.  extra. 

KEEN'S  CLINICAL  CHARTS.  Seven  Outline  Drawings  of  the 
Body,  on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Each  Drawing  may  be  had  separately,  twenty-five 
to  pad,  25  cents. 

SCHREINER.  Diet  Lists.  Arranged  in  the  form  of  a  chart. 
With  Pamphlets  of  Specimen  Dietaries.     Pads  of  50.  .75 

THROAT  AND    NOSE   (see  also  Ear). 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.  Diseases  of  the  Nose  and  Throat.  2d  Edition,  Enlarged. 
Two  Colored  Plates  and  80  Illustrations.  $2.75 

HOLLOPETER.     Hay  Fever.     Its  Successful  Treatment.      Ji.oo 

KNIGHT.  Diseases  of  the  Throat.  A  Manual  for  Students. 
Illustrated.  Nearly  Ready. 

LAKE.  Laryngeal  Phthisis,  or  Consumption  of  the  Throat. 
Colored  Illustrations.  $2  00 

MACKENZIE.  Pharmacopoeia  of  the  London  Hospital  for 
Dis.  of  the  Throat.    5th  Ed.,  Revised  by  Dr.  F.  G.  Harvey.  |i.oo 

McBRIDE.  Diseases  of  the  Throat,  Nose,  and  Ear.  With  col- 
ored Illustrations  from  original  drawings.    3d  Edition.  J7.00 

POTTER.  Speech  and  its  Defects.  Considered  Physiologically, 
Pathologically,  and  Remedially.  |i.oo 

SHEILD.     Nasal  Obstructions.     Illustrated,  I1.50 

URINE  AND  URINARY  ORGANS. 

ACTON.  The  Functions  and  Disorders  of  the  Reproductive 
Organs  in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life, 
Considered  in  their  Physiological,  Social,  and  Moral  Relations. 
8th  Edition.  I1.75 


MEDICAL  BOOKS.  21 


BEALE.  One  Hundred  Urinary  Deposits.  On  eight  sheets, 
for  the  Hospital,  Laboratory,  or  Surgery.  Paper,  J2.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.  Illustrated  and  Interleaved.    6th  Ed.    ^i.oo 

KLEEN.     Diabetes  and  Glycosuria.  J2.50 

MEMMINGER.    Diagnosis  by  the  Urine.   2d  Ed.  24  lUus.  |i.oo 

MORRIS.  Renal  Surgery,  with  Special  Reference  to  Stone  in  the 
Kidney  and  Ureter  and  to  the  Surgical  Treatment  of  Calculous 
Anuria.     Illustrated.  $2.00. 

MOULLIN.  Enlargement  of  the  Prostate.  Its  Treatment  and 
Radical  Cure.     2d  Edition.     Illustrated.  t^-75 

MOULLIN.  Inflammation  of  the  Bladder  and  Urinary  Fever. 
Octavo.  #i-5o 

SCOTT.  The  Urine.  Its  Clinical  and  Microscopical  Examination. 
41  Lithographic  Plates  and  other  Illustrations.    Quarto.  Cloth,  I5.00 

TYSON.  Guide  to  Examination  of  the  Urine.  For  the  Use  of 
Physicians  and  Students.  With  Colored  Plate  and  Numerous  Illus- 
trations engraved  on  wood.    9th  Edition,  Revised,  $1-25 

VAN   NUYS.    Chemical  Analysis  of  Urine.    39  lUus,         Ji.oo 


VENEREAL  DISEASES. 

GOWERS.     Syphilis  and  the  Nervous  System.  $1.00 

STURGIS   AND   CABOT.      Student's    Manual    of   Venereal 

Diseases.     7th  Revised  and  Enlarged  Ed.     i2mo.  $1-25 


VETERINARY. 

BALLOU.    Veterinary  Anatomy  and  Physiology.    29  Graphic 
Illustrations.  .80;  Interleaved,  |i. 00 


WOMEN,  DISEASES  OF. 

BISHOP.     Uterine  Fibromyomata.    Their  Pathology,  Diagnosis, 
and  Treatment.     Illustrated.  Cloth,  I3.50 

BYFORD   (H.   T.).     Manual   of  Gynecology.    Second   Edition, 
Revised  and  Enlarged  by  100  pages.     341  Illustrations.  $300 

DUHRSSEN.     A  Manual    of  Gynecological    Practice.     105 
Illustrations.  $i-5o 

FULLERTON.     Surgical   Nursing.     3d   Edition,   Revised  and 
Enlarged.     69  Illustrations.  Ji.oo 

LEWERS.     Diseases  of  Women.    146  Illus.    5th  Ed.  Ji2.5o 

MONTGOMERY.      Practical    Gynecology.      A  Complete   Sys- 
tematic Text-Book.    527  Illustrations.     Cloth,  I5.00 ;  Leather,  $6.00 

ROBERTS.      Gynecological    Pathology.      With   127   Full-page 
Plates  containing  151  Figures.    Jusi  Ready.  |6.oo 

WELLS.     Compend  of  Gynecology.     Illustrated.     2d  Edition. 

.80 ;  Interleaved,  |i.oo 


22  SUBJECT  CATALOGUE. 

COMPENDS. 


From  The  Southern  Clinic . 

"  We  know  of  no  series  of  books  issued  by  any  house  that  so  fully 
meets  our  approval  as  these  ?Quiz-Compends?.  They  are  well  ar- 
ranged, full,  and  concise,  and  are  really  the  best  line  of  text-books  that 
could  be  found  for  either  student  or  practitioner." 


BLAKISTON'S  ?QUIZ-COMPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 
Price  of  each,  Cioth,  .80.         Interleaved,  for  taking  Notes,  $1.00. 

4^  These  Compends  are  based  on  the  most  popular  text-books 
and  the  lectures  of  prominent  professors,  and  are  kept  constantly  re- 
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subjects  upon  which  they  treat. 

J9^  The  authors  have  had  large  experience  as  Quiz-Masters  and 
attaches  of  colleges,  and  are  well  acquainted  with  the  wants  of  students. 

t^  They  are  arranged  in  the  most  approved  ;form,  thorough  and 
concise,  containing  over  6oo  fine  illustrations,  inserted  wherever  they 
could  be  used  to  advantage. 

Jt^  Can  be  used  by  students  of  any  college. 

H^  They  contain  information  nowhere  else  collected  in  such  a 
condensed,  practical  shape.     Illustrated  Circular  free. 

No.  I.  POTTER.  HUMAN  ANATOMY.  Sixth  Revised  and 
Enlarged  Edition.  Including  Visceral  Anatomy.  Can  be  used 
with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and  16 
Lithographic  Plates  of  Nerves  and  Arteries,  with  Explanatory 
Tables,  etc.  By  Samuel  O.  L.  Potter,  m.d..  Professor  of  the 
Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  San 
Francisco  ;  Brigade  Surgeon,  U.  S.  Vol. 

No.  2.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  Sixth 
Edition,  Enlarged  and  Improved.  By  Daniel  E.  Hughes,  m.d., 
Physician-in-Chief,  Philadelphia  Hospital,  late  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College,  Phila. 

No.  3.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  II. 
Sixth  Edition,  Revised  and  Improved.     Same  author  as  No.  2. 

No.  4.  BRUBAKER.  PHYSIOLOGY.  Tenth  Edition,  with 
Illustrations  and  a  table  of  Physiological  Constants.  Enlarged 
and  Revised.  By  A.  P.  Brubaker,  m.d..  Professor  of  Physiology 
and  General  Pathology  in  the  Pennsylvania  College  of  Dental 
Surgery;  Adjunct  Professor  of  Physiology,  Jefferson  Medical 
College,  Philadelphia,  etc. 

No.  5.  LANDIS.  OBSTETRICS.  Seventh  Edition.  By  Henry  G. 
Landis,  m.d.  Revised  and  Edited  by  Wm.  H.  Wells,  m.d.. 
Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  College, 
Philadelphia.     Enlarged.     52  Illustrations. 

No.  6.  POTTER.  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PRESCRIPTION  WRITING.  Sixth  Revised  Edition 
(U.  S.  P.  1890).  By  Samuel  O.  L.  Potter,  m.d..  Professor  o( 
Practice,  College  of  Physicians  and  Surgeons,  San  Francisco; 
Brigade  Surgeon,  U.  S.  Vol. 


MEDICAL  BOOKS. 


PQUIZ-COMPENDS  ?— Continued. 

No.  7.  WELLS.  GYNECOLOGY.  Second  Edition.  ByWin.  H. 
Wells,  m  d.,  Demonstrator  of  Clinical  Obstetrics,  Jefiferson 
Medical  College,  Philadelphia.     140  Illustrations. 

No.  8.  GOULD  AND  PYLE.  DISEASES  OF  THE  EYE 
AND  REFRACTION.  Second  Edition.  Including  Treatment 
and  Surgery,  and  a  Section  on  Local  Therapeutics.  By  Georgb 
M.  Gould,  m.d.,  and  W.  L.  Pyle,  m.d.  With  Formulae,  Glossary 
Tables,  and  109  Illustrations,  several  of  which  are  Colored. 

No.  9.  HORWITZ.  SURGERY,  Minor  Surgery,  and  Bandag- 
ing. Fifth  Edition,  Enlarged  and  Improved.  Ky  Orville 
HoKwiTZ,  B.  s.,  M.D.,  Clinical  Professor  of  Genito-Urinary  Surgery 
and  Venereal  Diseases  in  JeflFerson  Medical  College ;  Surgeon  to 
Philadelphia  Hospital,  etc.    With  98  Formulae  and  71  Illustrations. 

No.  10.  LEFFMANN.      MEDICAL    CHEMISTRY.      Fourth 

Edition.  Including  Urinalysis,  Animal  Chemistry,  Chemistry  of 
Milk,  Blood,  Tissues,  the  Secretions,  etc.  By  Henry  Leffmann, 
M.D.,  Professor  of  Chemistry  in  the  Woman's  Medical  College  of 
Penna  ;  Pathological  Chemist,  Jefferson  Medical  College  Hospital. 
No.  II.  STEWART.  PHARMACY.  Fifth  Edition.  Based  upon 
Prof.  Remington's  Text-Book  of  Pharmacy.  By  F.  E.  Stewart, 
M.D.,  PH.G.,  late  Quiz-Master  in  Pharmacy  and  Chemistry,  Phila- 
delphia College  of  Pharmacy;  Lecturer  at  Jefferson  Medical 
College.     Carefully  revised  in  accordance  with  the  new  U.  S.  P. 

No.  12.  BALLOU.  VETERINARY  ANATOMY  AND  PHY- 
SIOL9GY.  Illustrated.  By  Wm.  R.  Ballou,  m.d..  Professor 
of  Equine  Anatomy  at  New  York  College  of  Veterinary  Surgeons ; 
Physician  to  Bellevue  Dispensary,  etc.     29  graphic  Illustrations 

No.  13.  WARREN.  DENTAL  PATHOLOGY  AND  DEN- 
TAL MEDICINE.  Third  Edition,  Illustrated.  Containing 
a  Section  on  Emergencies.  By  Geo.  W.  Warren,  d.d.s..  Chief 
of  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery. 

No.  lA.  HATFIELD.  DISEASES  OF  CHILDREN.  Second 
Edition.  Colored  Plate.  By  Marcus  P.  Hatfield,  Profes- 
sor ot  Diseases  of  Children,  Chicago  Medical  College. 

No.  15.  THAYER.   GENERAL  PATHOLOGY.   By  A.  E. 

Thayer,  m.d.,  Cornell  University  Medical  College.     Illustrated. 

No.  16.  SCHAMBERG.  DISEASES  OF  THE  SKIN.  Second 
Edition.  By  Jay  F.  Schamberg,  m.d..  Professor  of  Diseases  of 
the  Skin,  Philadelphia  Polyclinic.  Second  Edition,  Revised  and 
Enlarged.     105  handsome  Illustrations. 

No.  17.  GUSHING.  HISTOLOGY.  By  H.  H.  Gushing,  m.d.. 
Demonstrator  of  Histology,  Jefferson  Medical  College,  Philadel- 
phia.    Illustrated. 

No.  i8.  THAYER.  SPECIAL  PATHOLOGY.  Illustrated.  By 
same  Author  as  No.  15. 

Price,  each,  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1.00. 

Careful  attention  has  been  given  to  the  construction  of  each  sentence, 
and  while  the  books  will  be  found  to  contain  an  immense  amount  of 
knowledge  in  small  space,  they  will  likewise  be  found  easy  reading  ; 
there  is  no  stilted  repetition  of  words  ;  the  style  is  clear,  lucid,  and  dis- 
tinct. The  arrangement  of  subjects  is  systematic  and  thorough  ;  there 
Is  a  reason  for  every  word.    They  contain  over  600  illustrations 


THE  STANDARD  TEXT-BOOK 

Morris^  Anatomy 

SECOND  EDITION 

Rewritten,    Revised.    Improved 

WITH  MANY  NEW  ILLUSTRATIONS 


Has  been  recommended  as  a  text-book  at  more  than 
seventy  of  the  most  prominent  medical  schools  in  the  United 
States  and  Canada,  and  is  considered  by  all  anatomists  as  a 
standard  authority.  It  contains  many  features  of  special 
advantage  to  students.  A  complete  Text-book.  Edited  by 
Henry  Morris,  f.r.c.s.,  Surgeon  to,  and  Lecturer  on 
Anatomy  at,  Middlesex  Hospital,  assisted  by  J.  Bland 
Sutton,  f.r.c.s,,  J.  H.  Davies-Colley,  f.r.c.s.,  Wm.  J. 
Walsham,  f.r.c.s.,  H.  St.  John  Brooks,  m.d.,  R.  Mar- 
cus GuNN,  f.r.c.s.,  Arthur  Hensman,  f.r.c.s.,  Fred- 
erick Treves,  f.r.c.s.,  William  Anderson,  f.r.c.s.. 
Prof.  W.  H.  A.  Jacobson,  and  Arthur  Robinson,  m.r.c.s. 

Octavo.    With  790  Illustrations,  of  which  a  large  number 
are  printed  in  colors 

CLOTH.  $6.00:    LEATHER.  $7.00 


"  The  ever-growing  popularity  of  the  book  with  teach- 
ers and  students  is  an  index  of  its  value,  and  it  may  safely 
be  recommended  to  all  interested," — From  The  Medical 
Record^  New  York. 

"  Of  all  the  text-books  of  moderate  size  on  human 
anatomy  in  the  English  language,  Morris  is  undoubtedly 
the  most  up-to-date  and  accurate." — From  The  Philadel- 
phia Medical  Journal. 

THUMB  INDEX  IN  EACH  COPY 


UNIVERSITY  OF  CACiFCK^i^IBRARY 

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